Health History
Introduction
• Health history
 Comprehensive record of patient’s past & current
health
 Gathered during initial interview
 Goal
o Obtain information about the patient’s
health status
 Fosters communication
o Medical history
 By contrast, focuses on patient’s
past & present illnesses, medical
problems, hospitalizations, & family
history
• Health People 2020
 Government-designed plan describing objectives
& goals intended to help individuals attain highquality, longer lives free of preventable disease
Components of Health History
• Recorded in a system of documentation
 Electronic health record (EHR) & electronic
medical record (EMR) most commonly used
• Purpose
• Types
 Complete includes:
o Biographical data
o Reason for seeking care
o Current & past health status
o Family history
o Review of systems
o Psychosocial profile
o Current medication
 Focused – focuses on acute problem
o Includes the same components as
complete but only as it relates to specific
reason for seeking care or as would
affect the acute problem
 Which type to use depends on:
o Patient’s condition
o Amount of time
• Key Points to Remember When Obtaining Health
History
 Listen to what the patient is telling you both
verbally & non-verbally
 Don’t rush; allow enough time to obtain the data
 Ensure confidentiality
 Provide a private, quiet, comfortable environment
 Avoid interruptions
 Tell your patient how long the interview will take &
why you need to ask these questions
 Do NOT be so concerned about completing forms,
that you neglect the patient
 Start w/ what the patient perceives as the problem
 Use open-ended questions to elicit the patient’s
perspective
 Attend to any acute problems such as pain, before
obtaining a detailed history
 Remember that quality is more important than that
quantity of information obtained
• Outline
 Biographic data
 Reason for seeking care
 History of Present Illness/Current health
status/present health status
 Past history
 Family history
 Psychosocial history
 Review of body systems
• Biographic Data
 Demographic data about the patient
 Establish trust & rapport prior to asking questions
about sensitive information such as sexual health
 Name & address
 Age & date of birth
 Birthplace
o Environmental & cultural factors that
contributed to patient’s health
o Determine length of time patient spent in &
near place of birth & places patient moved
prior to current residence
 Gender
o Associated health risks
o Transgender individuals
 Marital status
o Asking if person in partnership includes all
sexual orientations
 Sexual orientation
o Orientation labels include straight, lesbian,
gay, bisexual, trans, queer, etc.
 Race/ethnicity/nationality
o Shared biologic & genetic traits
 Religion
o Organizing framework for beliefs &
practices
o Can impose restrictions that have an impact
on health
 Occupation
o Determines whether physical,
psychological, or environmental factors
impact patient’s health
 Health insurance
o Does not indicate patient’s inclination to
participate in healthcare
 Source of information
o Patient is primary source
 Reliability of source
o Person providing information is able to
provide clear, accurate account (consistent
info)
 Referral
o Identifies primary care
physician/practitioner; if NO referral source
identified, may need to make referral for
follow-up
 Advance directives
o Allows you to comply w/ patient’s
healthcare wishes if advance directives
exist
 Education/educational level
o Helps determine teaching approaches; do
NOT assume educational level correlates
w/ knowledge & understanding (ex. Diabetic
PhD holder who is unfamiliar w/ the disease
& its management)
o Do NOT talk down to patient who has had
little formal education
• Reason for Seeking Care – also known as chief
complaint, presenting problem, or reason for the visit:
 Ask your patient why she/he is seeking healthcare
 Document patients’ direct quote (list patient’s
statements)
 Gives you the patient’s perspective on the problem
through their eyes
o (ex. Tell me why you came to the clinic
today?)
o (ex. What happened that brought you to the
hospital?)
• Current Health Status – also culled current health
status; Present Health History
 Primary healthcare – reason of seeking care
generally relates to health maintenance or
promotion
o Usual state of health
o Any major health problems
o Usual patterns of health of healthcare
o Any health concerns
 Secondary level – reason for seeking care is
when there is an acute problem; ask the patient to
state what the problem is & how long it has been
going on
 Tertiary level – reason for seeking care is when
there is a well-defined problem, chronic problem,
or acute problem that is resolving
• Mnemonic devices:
 OLDCARTS
o Onset
o Location
o Duration
o Character
o Associated or aggravating factors
o Relieving factors
o Timing
o Severity
 PQRSTU
o Provocative or Palliative
o Quality or Quantity
o Region or Radiation/Related symptoms
o Severity/Severity Scale
o Timing (Onset, Duration, Frequency)
o Understanding patient’s perception
 COLDSPA
o Character
o Onset
o Location
o Duration
o Severity
o Pattern
o Associated factors/how it affects the patient
 LOIQAPF
o Location
o Onset
o Intensity
o Quality
o Aggravating/Associated/Alleviating factors
o Pain Goal
o Functional Goal
• At the secondary & tertiary levels patients have
existing problems
 Symptom analysis needs to be performed to
assess your patient’s presenting symptoms
thorough
o Try to determine how disabling the problem
is for your patient
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o
o
o
o
• Using PQRSTU in Symptom analysis
o Precipitating/Palliative factors
 What were you doing when the
problem started?
 Does anything make it better, like
medications or certain positions?
o
Does anything make it worse, like
movement or breathing?
Quality/Quantity
 Can you describe the symptom?
 What does it feel like, look like, or
sound like?
 How often are you experiencing it?
 To what degree does this problem
affect your ability to perform your
usual daily activities?
 If the patient has difficulty
answering the question you
can provide suggestions
Region/Radiation related symptoms
 Can you point to where the problem
is?
 Does it occur or spread anywhere
else?
 Do you have any other symptoms?
Severity
 Is the symptom mild, moderate, or
severe?
 Grade it on a scale of 0 – 10
 0 = no pain
 10 = worst pain
Timing
 When did the symptom start?
 How often does it occur?
 How long does it last?
Treatment
 Have you taken any medication?
 What others treatments have you
tried?
o Understand
 What do you think the cause is?
• Current Medications
 Pertains to medications taken by the client at
home or at the onset of symptom; or alternative
medications taken in the hospital NOT prescribed
by the physician
 Note all prescription & OTC medications & herbal
remedies
 Ask specifically for vitamins, birth control pills,
aspirin, & antacid
• Medications
 Prescription & over-the-counter
 Patient’s level of knowledge regarding medication
 Use of home remedies, folk remedies, vitamins, &
supplements
 Reconciliation provides specific information
• Sample chart
• Family History (genogram)
• Provides clues to genetically linked or familial disease
that may be risk factors for your patient
• Ask about:
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Heart disease
High blood pressure
Stroke
Diabetes
Cancer
Obesity
Bleeding disorders
Tuberculosis
Renal disease
Seizures
Mental disease
• Traditionally focused on inherited conditions caused
by a defect in a single gene or chromosome
• Virtually all diseases & health conditions have a
genetic component
• Ask about health status & ages of your patient’s family
members
• What can family history tell you?
• Past History
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Patient
Children
Siblings
Grandparents
Spouse
Parents
 Aunts & Uncles
• Family history
 “1st
genetic test”
o Nurses expected to be competent in
collecting family history info
 Pedigree/genogram/family tree
o Pictorial representation that helps in the
identification of “red flags” for patient
referral to a genetic specialist
o Should include 3 generations
• Sample Genogram
• Psychosocial History
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Mental
Emotional
Social functioning
Spiritual
• What can psychosocial history tell you?
 Identify patient’s ability to comprehend verbal &
written language
 Determine role & relationships & support systems
o Influenced by culture
• Psychosocial history – psychosocial profile gives you
a picture of your patient’s health promotion & preventive
patterns
• Psychosocial functioning
 The way a person thinks, feels, acts, & relates to
self & others
 Ability to cope & tolerate stress
 Capacity for developing a value & belief system
• Changes in psychosocial functioning may affect a
patient’s physical health or response to treatment
• Dimensions
• Factors that influence psychosocial health
 Internal
o Genetics
 Predisposition for developing
hypertension, ADHD, & conditions
such as obesity, alcoholism, &
hypoglycemia
 Characteristics result in reactions
from others that can have an impact
on the developing personality
o Physical health
 Mind-body-spirit connection
 Enables individual to respond to
stressors & cope w/ change
 Emotional stress
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Affects immune system
Individuals less likely to attend
to habits that promote health
 Link between prolonged
stress, obesity
o Developmental stage
 Children
 Inability to understand cause
& effect
 Helpful to allow to touch &
manipulate equipment prior to
procedure
 Older adults
 Functional ability
 Cognition
 Lifestyle changes
o Physical fitness
 Condition that helps individual feel,
appear, & perform at an optimal level
 Components
 Cardiovascular fitness
 Body composition
 Muscular endurance
 Strength
 Flexibility
 External
o Family
 Child rearing, care-giving
 Expected to provide for physical
safety & economic needs, help each
individual develop identity as self &
member of family
o Culture

Complex system that includes
knowledge, beliefs, morals, &
customs
o Geography
 Country, region, section, community,
or neighborhood in which one was
born, raised, or currently resides or
works
 Climate, terrain, resources, &
aesthetics affect psychosocial health
 Access to healthy food, exercise,
education
o Economic status
 The higher the income, the more
likely that individuals will have higher
levels of education
 Contributes to high self-worth
& self-esteem
 Impoverished groups more likely to
be focused on immediate needs of
the present
 Interpersonal
o Role development
 Individual’s capacity to identify &
fulfill social expectations related to
roles assumed in lifetime
 Roles learned through socialization
o Sexuality
 Sexual identity
 Self-assigned & defines
attractions, behaviors,
desires, & fantasies
 Sexual orientation label

Straight, lesbian, gay,
bisexual, trans, queer, etc.
 Transgender
 Gender nonconforming &
NOT associated w/ specific
orientation label
 Interdependent relationship
 Those in which individuals
establish bonds w/ others
based on trust
 Generally loving & close
relationships between those
who have similar levels of
self-esteem
 Coping & stress management
o Stress & coping
 Physical & emotional response to
threats called stressors
 Different for everyone
 Fight-or-flight versus long-term
 Positive & negative events can
cause stress
 Stress itself NOT always bad
o Spiritual & belief patterns
 Individual’s relationship w/ higher
power or ideal
 Moral code
 Many different approaches
 Belief system
o Self-concept
 Beliefs & feelings one holds about
oneself
 Includes body image & self-esteem
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Overweight & obese children
prone to low self-esteem,
depression, & suicidal
thoughts
Feeding & eating disorders
 Anorexia nervosa
 Bulimia nervosa
• Nursing Process in Psychosocial Assessment
 Skills required
o Knowledge
o Effective communication
o Critical thinking
 Holistic approach
• Assessment
 Begins before initial interview
 If area of heightened concern discovered, nurse
may conduct focused interview
 Psychosocial well-being
o In some situations, NOT apparent at time of
interview
o Affects patients w/ substance abuse,
depression, neurosis, or psychosis
 History of psychosocial concerns
o Some being early in life & reappear when
patient faces major stressor
o Past coping & treatment inform treatment
for current issue
 History of physiologic alterations or disease
o Understanding of mind-body link
o Affective problems related to symptoms
 Self-concept
o Most patients find it embarrassing to
divulge until a positive nurse-patient
relationship has been established
 Family history
o Psychosocial dysfunction
o Ask questions regarding parents, siblings,
extended, & current family
 Other roles & relationships
o Close friends, neighbors, & coworkers
o Community or social groups
 Stress & coping
o Greatly affected by number & severity of
stressors over one’s lifetime
o Holmes Social Readjustment Rating Scale
(SRRS)
o Self-directed violence (SDV)
 Behavior committed by & aimed at
oneself that results in deliberate
actual or potential self-harm
o Suicidal ideation
 Considering, planning, or thinking
about suicide
 Notify primary care provider
 Sensory perception & cognition
o Direct questioning of the disoriented patient
may increase patient’s anxiety & escalate
abnormal behavior
o Assess content of patient’s hallucinations
for safety concerns
 Spiritual & belief systems
o Effect of ethical, moral, & religious values
on patient’s health status
o May include culturally derived beliefs about
health, illness, God
o Be careful about querying a patient who is
hallucinating or delusional
 Physical observation
o Patient’s general appearance, posture, gait,
body language, & speech patterns
o Measures, scales available for assessing
aspects of psychosocial health
 Includes Body Image Ideals
Questionnaire, Body Image quality of
Life inventory
o Multidimensional Health ProfilePsychosocial (MHP-P)
• Organizing the Data
 Nurse sorts, groups, & categorizes information
 Holistic approach
o Individual must be viewed as a total being
for whom body, mind, & spirit continuously
interact w/ self & environment
Review of Systems (ROS) also called a systems
enquiry or systems review – is a technique used by
healthcare providers for eliciting a medical history from a
patient through a litany of questions specific to each
body system
 Is an inventory of the body systems that is
obtained through a series of questions in order to
identify signs and/or symptoms which the patient
may be experiencing
 ROS is used to obtain the current & past health
status of each system & to identify health
problems that your patient may have failed to
mention previously
 Provides clues to health promotion activities for
each particular system
 Identify health promotion activities & provide
instruction as needed
 Subjective assessment of health history
• Review of body systems
 Provides subjective information about each
body system & its organs
 Open-ended questions are best for eliciting
information about abnormal symptoms
 Format
o Cephalocaudal or head-to-toe
o Approach related to nursing theory
 ROS questions may uncover problems that the
patient has overlooked, particularly in areas
unrelated to the present illness
 Significant health events such as a major illness or
a parent’s death require full exploration
• Components of the Review of Systems
• Documentation
 Health history influenced by agency or facility in
which interview is carried out
 Part of the patient record & a legal document
 Subjective data between quotation marks
 Present data in clear & concise manner
• Nursing Considerations
 Ability of patient to participate in interview process
o Culture & language
o Alterations in senses
o Developmental level
• Examples