Tuesday, October 12, 2010

Components of the Health History

Identifying Data
Reliability
Chief Complaint(s)
Present Illness
Past History
Family History
Personal and Social History
Review of Systems
occupation, marital status
Identifying data—such as age, gender,
can be family member, friend, letter of
referral, or the medical record
Source of the history—usually the patient, but
If appropriate, establish source of referral,
since a written report may be needed.
Varies according to the patient’s memory,
trust, and mood
The one or more symptoms or concerns
causing the patient to seek care
how each symptom developed
Ampli.es the Chief Complaint, describes
about the illness
Includes patient’s thoughts and feelings
Systems
Pulls in relevant portions of the Review of(see below)
May include medications, allergies, habits of
smoking
frequently pertinent to the present illness
and alcohol, since these are
Lists childhood illnesses
four categories: medical; surgical; obstetric/
gynecologic; and psychiatric
Lists adult illnesses with dates for at least
as: immunizations, screening tests, lifestyle
issues, and home safety
Includes health maintenance practices such
age and cause of death of siblings, parents,
and grandparents
Outlines or diagrams of age and health, or
illnesses in family, such as hypertension,
coronary artery disease, etc.
Describes educational level, family of origin,
current household, personal interests, and
lifestyle
Documents presence or absence of common
symptoms related to each major body system
Documents presence or absence of speci.c

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