Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History

Otterbein University Graduate Studies in Nursing Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History 

Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History

Appendix C

Comprehensive Health History

 

Take the information from the ShadowHealth Health History and place in this format

 

Comprehensive Adult Health History (taken from Bickley, 2017)

1. PROBLEM LIST
2. Active problems
3.  Inactive problems

III. Risk factors

 

1. COMPREHENSIVE HISTORY (Subjective Data) –

 

Date & Time

 

Client Identifying data (initials only!)

May include age, gender, occupation, marital status

Source of data – (most often the patient, can be a family member or friend, the medical record, etc)

Reliability- include if relevant

 

Chief complaint(s) /presenting problem

One or more symptoms or concerns causing the patient to seek care; be brief and try to quote patient’s own words

PI (History of Presenting Illness)

Complete, clear and chronological account of the problems prompting the patient to seek care. Include 1) location; 2) quality or character; 3)quantity or severity; 4) timing, including onset, duration and frequency; 5) the setting in which it occurs; 6) factors that have aggravated or relieved the symptoms; and  7) associated symptoms. Include  pertinent positives and negatives from the section of the Review of Systems related to the Chief Complaint. These include the presence or absence of symptoms relevant to the differential diagnosis. (some find the OLDCARTS mnemonic helpful) Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History .

 

Include other relevant information – such as risk factors for CAD in patients with chest pain.

Include the response to the symptoms and the effect the illness has had on the patient’s life.

Other symptoms or concerns need a separate description and paragraph.

(This needs to be written in chronological order, describe the current episode and then from the onset until now)

 

Medications – Note name, dose, route, frequency. Include OTC, herbal, vitamins and minerals, inhalers, ear and eye medications

 

Allergies –include specific reactions to medications, such as rash, and allergies to food, insects or environmental factors

Tobacco Use – report cigarettes in pack years. Note how long someone has quit.

Alcohol and Drug use

 

Past Medical History

 

Childhood Illnesses

Include:  measles, rubella, mumps, pertussis or whooping cough, chicken pox, rheumatic fever, scarlet fever, polio,  and any chronic childhood illnesses

 

 

Adult Illnesses

Medical:  Illnesses such as diabetes, hypertension, hepatitis, asthma, HIV,

Hospitalizations: dates and reason

Surgical:  Dates, indications, type of surgery, outcomes

OB/GYN/Sexual history-pregnancies, births, miscarriages/AB , menstrual history, methods of contraception, sexual function, number and gender of sexual partners, safe sex practices

Psychiatric: Illnesses and time frame, diagnoses, hospitalizations and treatments

Health Maintenance- immunizations –vaccines for  tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenzae type B, pneumococci, and herpes zoster.

Screening tests – Tb tests, pap smears, mammograms, stool for occult blood, colonoscopy, cholesterol – results and last performed.

Family History

Create a genogram  –

Include age, health or cause of death, of immediate family members (parents, grandparents, siblings, children and grandchildren).

Ask about each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease,  elevated cholesterol levels, stroke, diabetes, thyroid or renal disease,  arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies. Ask about any history of breast, ovarian, colon or prostate cancer, and any genetically transmitted diseases.

 

Personal and Social History

Includes occupation, education, home situation, significant others, sources of stress, important life experiences, leisure activities, religious affiliation and spiritual beliefs, and activities of daily living (ADLs), lifestyle habits:  exercise, diet, usual daily food intake, dietary supplements or restrictions, use of coffee, tea and other caffeinated beverages, sleep habits, safety measures such as use of seat belts, bicycle helmets, sun block, smoke detectors. Include alternative health care practices

 

Review of systems

               General: usual weight, recent weight change, clothing fits more tightly or loosely than before, weakness, fatigue, fever

 

Skin:  rashes, lumps, sores, itching, dryness, color changes, changes in hair or nails, changes in size or color of moles

 

Head:  headaches, head injury, dizziness, lightheadedness

 

Eyes:  vision, glasses or contact lenses, last eye exam, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts

 

Ears:  Hearing, tinnitus, vertigo, earaches, infections, discharge, hearing aids

 

Nose/sinuses:  frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble

 

Throat: Condition of teeth, gums, bleeding gums, dentures/fit,  last dental exam, sore tongue, dry mouth, frequent sore throats, hoarseness

 

Neck:  swollen glands, goiter, lumps, pain, or stiffness in neck

 

Breasts:  lumps, pain or discomfort, nipple discharge, self-exam practices

 

Respiratory:  cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last CXR

 

Cardiac:  heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, ECG or other cardiac tests

 

GI:  trouble swallowing, heartburn, appetite, nausea, vomiting, bowel movements, stool color and size, change in bowel habits, pain with defecation, rectal bleeding, or black or tarry stools, hemorrhoids, constipation or diarrhea, abdominal pain, food  intolerance, excess belching or passing gas,  jaundice, liver or gallbladder, problems, hepatitis

 

Peripheral vascular:  intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet, color change in fingertips or toes during cold weather, swelling with redness or tenderness

 

Urinary:  frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; for men: reduced caliber or force of the urinary stream, hesitancy, dribbling

 

Genital: Male:   hernias, discharge from or sores on penis, testicular pain or masses, scrotal pain or swelling, history of sexual transmitted infections and their treatment, sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems, concern about HIV infection

 

Female: Age at menarche, regularity, frequency and duration of periods, amount of bleeding, bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension,  age at menopause, menopausal symptoms, postmenopausal bleeding, exposure to DES (if born before 1971). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions, complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction any problems including dyspareunia, concerns about HIV infection

 

Musculoskeletal:  muscle or joint pain, stiffness, arthritis, gout, backache, neck paint. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness or limitation of motion or activity. Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness. Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History

 

Psychiatric:  Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant

 

Neurologic:  Changes in mood, attention or speech, change in orientation, memory or insight, or judgment, headache, dizziness, vertigo, fainting, blackouts, weakness,  paralysis, numbness or loss of sensation, tingling, or “pins and needles”,  tremors, or other involuntary movements, seizures

 

Hematologic:  anemia, easy bruising or bleeding,  past transfusions, transfusion reactions

 

Endocrine:  “thyroid trouble”, heat or cold intolerance, excess sweating, excess thirst or hunger, polyuria, change in glove or shoe size

Appendix C (continued)

Grading Rubric: Comprehensive Adult Health History

	Partial points	Partial points	Full points
Chief Complaint	Both not a quote and too wordy (0)	Either not a quote or too wordy (1)	In patient’s own words & concise, time frame if appropriate (2 points )
HPI	Missing > one component of HPI, not chronological or coherent  (1-3)	Missing one component of HPI, or missing significant positives and negatives (4)	Chronological, includes 7 components, includes significant positives and negatives (5)
Medications, Allergies, LMP	Missing at least one component (0)	Includes names of Meds, Allergies and LMP but missing other details(1)	Includes all medications, reason for meds, how taken; allergies to medications, environmental factors and food, and how allergies are manifest; includes LMP if childbearing age (2)
PMH	Missing more than one component (1-2)	Missing one or more component, or component not complete  (3)	Includes all components: childhood Illnesses, Adult illnesses, (Medical, Hospitalizations, Surgeries, OB/GYN hx, Psych, Accidents, Health Maintenance) Includes negatives for major illnesses  (4)
Family History	Missing > one component (1)	Missing one component or component not complete (2)	Includes genogram with parents, grandparents, children and major significant chronic illness; asks about illnesses listed in Bates for FH (3)
Personal Social History	Missing > one component (1)	Missing one component or component not complete (2)	Includes all of the categories listed in the Adult Health History Sheet (3)
Review of Systems	Missing > one component (1-3)	Missing one component or component not complete (4)	Includes 20 systems as laid out in Bates, includes important negatives at least to the detail in chapter 2 in text (5)
Problem List	Missing >1 problem (1)	Problem list missing an important problem (2)	Problem list appropriate and complete based on history (3)
Overall	Unclear in several sections, not well organized (1)	Mostly well organized and clear (2)	Well organized, easy to read and follow, typed (3) Nursing 6830 Spring 2021 Tina Jones Comprehensive Health History