Health History
Why this is important
The process of obtaining a health history is an essential component to the effective performance of the
nurse. You will learn how to utilize effective communication techniques to establish rapport in a nursepatient relationship. You will then learn the critical components of a health history and how to obtain the
information. Your ability to perform this skill is key in providing optimal patient care.
What you will learn to do
Obtain a health history
Knowledge and skills you will learn along the way
This learning plan addresses the following learning objectives to help you master the competency:
a. Define key terms.
b. Compare and contrast subjective data and objective data.
c. State the purpose of a complete health history.
d. Describe the data or information that must be gathered for each category of a health history.
e. Describe the eight critical characteristics, using the PQRSTU mnemonic, that should be
included in the summary of each client symptom.
f. Compare and contrast signs and symptoms.
g. Identify the purpose of utilizing a variety of communication techniques to appropriately
gather data.
h. Describe how nonverbal behaviors affect communication in both positive and negative
manners.
i. Examine various communication barriers.
j. Formulate measures to maintain confidentiality of patient information.
k. Describe developmental and cultural differences to take into consideration.
l. Explain how to properly document findings.
Learning Activities
a. PREVIEW the Performance Standards and Learning Objectives for this competency outlined
b.
c.
d.
e.
above.
READ Potter and Perry Chapters 3(Communication) and 4 (Reporting and Recording).
READ Jarvis chapter 3 (The Interview) and chapter 4 (Health History)
VIEW or READ a presentation on obtaining a health history.
PRACTICE gathering health history data with a peer.
Assessment Activities
1. DEMONSTRATE satisfactory completion of performance check off
2. DOCUMENT health history findings on a flowsheet/nursing notes for evaluation by the
instructor.
3. DEMONSTRATE ability to apply knowledge by completing an exam.