Overview of this chapter

This chapter presents the importance of a health history as a component of health assessment and the value of a health history obtained from the perspective of a nurse. This chapter will provide information on components of a health history, considerations in obtaining a health history and documentation.

Health History

Purpose

The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).

Subjective Data

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The health history is the subjective data collection portion of the health assessment.

Components of a Health History

The health history obtained by nurses is framed from holistic perspectives of all factors that contributes to the patient’s current health status. The most common way of obtaining information is through an interview, primarily of the patient. When the patient is unable to provide information for various reasons, the nurse may obtain it from secondary sources.

The checklist below provides steps of obtaining a nursing history based that reflects its components such as biographical data, reason for seeking care, history of present illness, past health history, family history, functional assessment, developmental functions and cultural assessment. Each healthcare facility will have electronic and/or paper forms based on these components.

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

STEPS

ADDITIONAL INFORMATION

• Source of history
• Name
• Age
• Occupation (past or present)
• Marital status/living arrangement

• Chief complaint
• Onset of present health concern
• Duration
• Course of the health concern
• Signs, symptoms, and related problems

• Medications or treatments used (ask how effective they were)
• What aggravates this health concern
• What alleviates the symptoms
• What caused the health concern to occur
• Related health concerns
• How the concern has affected life and daily activities
• Previous history and episodes of this condition

• Allergies (reaction)
• Serious or chronic illness
• Recent hospitalizations
• Recent surgical procedures
• Emotional or psychiatric problems (if pertinent)
• Current medications: prescriptions, over­-the­-counter, herbal remedies
• Drug/alcohol consumption

• Pertinent health status of family members
• Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders

• Activity/exercise, leisure and recreational activities (assess for falls risk)
• Sleep/rest
• Nutrition/elimination
• Interpersonal relationships/resources
• Coping and stress management
• Occupational/environmental hazards

• Current significant physical and psychosocial changes/issues

• Cultural/health-related beliefs and practices
• Nutritional considerations related to culture
• Social and community considerations
• Religious affiliation/spiritual beliefs and/or practices
• Language/communication

Introductory Information: Demographic and Biographic Data

Name/contact information and emergency information

• What is your full name?
• What name do you prefer to be called by?
• What is your address?
• What is your phone number?
• Who can we contact in an emergency? What is their relationship to you? What number can we reach them at?

Birthdate and age

• What is your birthdate?
• What is your age?

Gender

• Tell me what gender you identify with.
• What pronouns do you use? (If the person asks you to use a pronoun that you are not familiar with, it is okay for you to respectfully respond, “I am not familiar with that pronoun. Can you tell me more about it?”)

Allergies

• Do you have any allergies?
• If so, what are you allergic to?
• How do you react to the allergy?
• What do you do to prevent or treat the allergy?

Note: You may need to prompt for information on medications, foods, etc.

Languages spoken and preferred language

• What languages do you speak?
• What language do you prefer to communicate in (verbally and written)?

Note: You may need to inquire and document if the client requires an interpreter.

Relationship status

• Tell me about your relationship status?

Occupation/school status

• What is your occupation? Where do you work?
• Do you go to school?

Resuscitation status

• We ask all clients about their resuscitation status, which refers to medical interventions that are used or not used in the case of an emergency (such as if your heart or breathing stops). You may need more time to think about this, and you may want to speak with someone you trust like a family member or friend. You should also know that you can change your mind. At this point, if any of this happens, would you like us to intervene?

Main Health Needs (Reasons for Seeking Care)

Presenting to a clinic or a hospital emergency or urgent care (first point of contact)

• Tell me about what brought you here today.

• • Tell me more.
  • How is that affecting you?

  Already admitted, and you are starting your shift

  • Tell me about your main health concerns today.
  • • Tell me more.
    • How is that affecting you?

    The PQRSTU Mnemonic

    Provocative

    • What makes your pain worse?

    Palliative

    • What makes your pain feel better?

    Quality

    • What does the pain feel like?

    Quantity

    • How bad is your pain?

    Region

    • Where do you feel the pain?
    • Point to where you feel the pain.

    Radiation

    • Does the pain move around?
    • Do you feel the pain elsewhere?

    Severity

    • How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?

    Timing

    • When did the pain start?
    • What were you doing when the pain started?
    • Where were you when the pain started?
    • Is the pain constant or does it come and go?
    • If the pain is intermittent, when did it last occur?
    • How long does the pain last?

    Treatment

    • Have you taken anything to help relieve the pain?
    • Have you tried any treatments at home for the pain?

    Understanding

    • What do you think is causing the pain?

    Current and Past Health

    Current health

    • Are there any other issues affecting your current health?

    Childhood illnesses

    • Tell me about any significant childhood illnesses that you had.
    • When did it occur?
    • How did it affect you?
    • How did it affect your day-to-day life?
    • Were you hospitalized? Where? How was it treated?
    • Who was the treating practitioner?
    • Did you experience any complications?
    • Did it result in a disability?

    Chronic illnesses

    • Tell me about any chronic illnesses you currently have or have had (e.g., cancer, cardiac, hypertension, diabetes, respiratory, arthritis).
    • • How has the illness affected you?
      • How do you cope with the illness?
      • When were you diagnosed?
      • Who was the treating practitioner?
      • How was the illness being treated?
      • Have you been hospitalized? Where?
      • Have you experienced any complications?
      • Has the illness resulted in a disability?
      • How does the illness affect your day-to-day life?

      Acute illnesses, accidents, or injuries

      • Tell me about any acute illnesses that you have had.
      • Tell me about any accidents or injuries you currently have or have had.
      • • When did it occur?
        • Were you hospitalized? Where?
        • How was it treated?
        • Who was the treating practitioner?
        • Did you experience any complications?
        • Has it resulted in a disability?
        • How did it affect your day-to-day life?

        Obstetrical health

        • Have you ever been pregnant?
        • Do you have plans to get pregnant in the future?
        • Tell me about your pregnancies.
        • Have you ever had difficulty conceiving?
        • How was your labour and delivery?
        • Tell me about your postpartum experience.
        • Were there any issues or complications?

        Mental Health and Mental Illnesses

        Mental health is an important part of our lives and so I ask all clients about their mental health and any concerns or illnesses they may have.

        Mental health

        • Tell me about your mental health.
        • Tell me about the stress in your life.
        • How does stress affect you?
        • How do you cope with this stress? (this may include positive or negative coping strategies.)
        • Have you experienced a loss in your life or a death that is meaningful to you?
        • Have you had a recent breakup or divorce?
        • Have you recently lost your job or been off work?
        • Have you recently had any legal issues?
        • Have you purchased any weapons?

        Mental illness

        • How does that illness affect you?
        • How does that illness affect your day-to-day life?
        • How do you cope with the illness?
        • What resources do you draw upon to cope with your illness?
        • When were you diagnosed?
        • Who was the treating practitioner?
        • Have you been hospitalized? Where?
        • Tell me about your treatment (e.g., medications, counselling).
        • Have you experienced any complications?
        • Has the illness resulted in a disability?
        • Do you have any concerns that have not been addressed related to your illness?

        Functional Health

        Nutrition

        • Tell me about your diet.
        • What foods do you eat?
        • What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.)
        • What have you consumed in the last 24 hours? Is this typical of your usual eating pattern?
        • Do you purchase and prepare your own meals?
        • Tell me about your appetite. Have you had any changes in your appetite?
        • Do you have any goals related to your nutrition?
        • Do you have the financial capacity to purchase the foods you want to eat?
        • Do you have the knowledge and time to prepare the meals you want to eat?

        Elimination

        • How often do you urinate each day?
        • What colour is it (amber, clear, dark)?
        • Have you noticed a strong odour?
        • How often do you have a bowel movement?
        • What colour is it (brown, black, grey)?
        • Is it hard or soft?
        • Do you have any problems with constipation or diarrhea? If so, how do you treat it?
        • Do you take laxatives or stool softeners?

        Sleep and rest

        • Tell me about your sleep routine.
        • • How much do you sleep?
          • Do you wake up at all?
          • Do you feel rested when you wake? What do you do before you go to bed (e.g., use the phone, watch TV, read)?
          • Do you take any sleep aids?
          • Do you have any rests during the day?

          Mobility, activity, exercise

          • Tell me about your ability to move around.
          • Do you have any problems sitting up, standing up or walking?
          • Do you use any mobility aids (e.g., cane, walker, wheelchair)?
          • Tell me about the activity and/or exercise that you engage in. What type? How frequent? For how long?

          Violence and trauma

          • Many clients experience violence or trauma in their lives. Can you tell me about any violence or trauma in your life?
          • How has it affected you?
          • Tell me about the ways you have coped with it.
          • Have you ever talked with anyone about it before?
          • Would you like to talk with someone?

          Relationships and resources

          • Tell me about the most influential relationships in your life.
          • Tell me about the relationships you have with your family.
          • Tell me about the relationships you have with your friends.
          • Tell me about the relationships you have with any other people.
          • • How do these relationships influence your day-to-day life? Your health and illness?
            • Who are the people that you talk to when you require support or are struggling in your life?

            Intimate and sexual relationships

            • I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships.
            • Tell me about the ways that you ensure your safety when engaging in intimate and sexual practices.
            • Do you have any concerns about your safety?

            Substance use and abuse

            • To better understand a client’s overall health, I ask everyone about substance use such as tobacco, herbal shisha, alcohol, cannabis, and illegal drugs.
            • Do you or have you ever used any tobacco products (e.g., cigarettes, pipes, vaporizers, hookah)? If so, how much?
            • When did you first start? If you used to use, when did you quit?
            • Do you drink alcohol or have you ever? If so, how often do you drink?
            • How many drinks do you have when you drink?
            • When did you first start drinking? If you used to drink, when did you quit?
            • Do you use or have you used any cannabis products? If so, how do you use them? How often do you use them?
            • When did you first start using them?
            • Do you purchase them from a regulated or unregulated place?
            • If you used to use cannabis, when did you quit?
            • Do you use any illegal drugs? If so, what type? How often do you use them?
            • Tell me about the ways that you ensure your safety when using any of these substances.
            • Have you ever felt you had a problem with any of these substances?
            • Do you want to quit any of these substances?
            • Have you ever tried to quit?

            Environmental health and home/occupational/school health

            • Tell me about any factors in your environment that may affect your health. Do you have any concerns about how your environment is affecting your health?
            • Tell me about your home. Do you have any concerns about safety in your home or neighbourhood?
            • Tell me about your workplace and/or school environment.
            • What activities are you involved in or what does your day look like?

            Self-concept and self-esteem

            • Tell me what makes you who you are.
            • Are you satisfied about where you are in your life?
            • Can you share with me your life goals?

            Other iADL

            • Tell me about how you take care of yourself and manage your home.
            • Do you have sufficient finances to pay your bills and purchase food, medications, and other needed items?
            • Do you have any current or future concerns about being able to function independently?

            Preventive Treatments and Examinations

            Medications

            • Do you have the most current list of your medications?
            • Do you have your medications with you? (If not, you should ask them to list each medication they are prescribed and if they know, the dose and frequency.)
            • Can you tell me why you take this medication?
            • How long have you been taking this medication?
            • Do you take the medications as prescribed? (If they answer “no” or “sometimes,” ask them to tell you the reasons for not taking the medications as prescribed.)

            Examination and diagnostic dates

            • When was the last time you saw [name the primary care provider, nurse or specialist]?
            • Can you share with me why you saw them?
            • When was the last time you had your [name screening] tested?
            • Do you know what the results were?

            Vaccinations

            • Can you tell me about your immunization status?
            • Can you tell me what immunizations you have had, the dates you received them, and any significant reactions?
            • Do you have your immunization record?
            • When was your last flu vaccine?

            If the client’s immunizations are not up-to-date or you noted vaccination hesitancy, you may ask:

            • Can you tell me the reasons that your immunizations are not up-to-date?
            • Can you tell me why you are hesitant to receive immunizations. (You may need to explore this further.)

            Family Health

            • Tell me about the health of your blood relatives.
              • Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)?
              • If so, do you know the cause of death?
              • And at what age did they die?
              • Has anyone been sick recently?
              • If so, do you know the cause?
              • What symptoms have they had?

              Cultural Health

              • I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?
              • • Tell me more.
                • How does that affect your health and illnesses?
                • Is there anything else you want to share about how these factors act as resources in your life?

                Learning Resource: Open the link below for more detailed information.

                Cultural factors in obtaining a health history

                When interviewing a patient the nurse must be aware of cultural barriers and preferences in order to collect significant and complete subjective data.. For example due to age, culture, or ethnicity, some patients may believe that pain is to be expected and endured. The patient may not identify their pain as worthy of report unless the nurse is sensitive to this potential barrier of care. Due to age, culture or ethnicity, some patients may feel uncomfortable discussing sexual health. For example, where HIV is epidemic, it is the nurse’s responsibility (along with all other healthcare personal) to uncover risk factors that can address safety and early treatment for STIs (sexually transmitted diseases). Culture can have many meanings. Some of the many aspects that nurses need to be aware of that will impact information obtained in a health history include gender identity, religion, geographical region, and many diverse factors. The nurse must be open to learning about various cultures and ethnicity and be comfortable in initiating a cultural assessment, and use this knowledge to enhance communication to obtain the most accurate health history.

                Health history and therapeutic communication

                

                Needless to say, therapeutic communication techniques are essential in obtaining a health history. However, due to many reasons, healthcare professionals, including nurses, oftentimes fail to establish a therapeutic relationship or to deliver therapeutic communication. The following are examples :

                • Have you ever been to see a healthcare provider and when they walk in the room they are not looking at you but are looking at the chart, or tapping on a computer.
                • Have you ever felt rushed by their questions, like they are in a hurry and need to move on to the next patient?
                • Have you ever had the healthcare provider give you a diagnosis, provide you with a treatment and you left with a prescription but you didn’t grasp the entire explanation?

                The nurse should apply communication and interpersonal skills to create, maintain, and terminate a nurse-client relationship. [] Nurses and other healthcare professionals need to use therapeutic communication techniques at all times.

                Open the link below for more detailed information

                Documentation of Health History:

                The patient’s health history is initially obtained during admission or initial visit, and constantly updated with subsequent interactions or visits. Documentation of information obtained during the nurse-patient interview, and/or secondary sources will need to be documented on a format that the healthcare facility uses. Nowadays, most healthcare facilities use electronic health records (EHR). EHRs are accessed by various members of the healthcare team in real-time, and this indicates that information obtained can be recorded during the interview process as well. The nurse needs to develop the competency to maintain therapeutic communication techniques while attending to the electronic health record keeping. Healthcare facilities use different documentation systems. Nurses will need to learn facility specific documentation system, whether electronic or paper, but the contents of a patient history will largely be similar.

                1. Open the clinical decision prompts to pause and reflect on the situation presented in this video:

                References

                LaPierre, D. (2010). Clinical assessment. Sharing in health.ca:open access training in healthcare.Retrieved at http://www.sharinginhealth.ca/clinical_assessment/clinical_assessment.html

                Nursing Documentation https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/NurseDocumentationPPT.pdf

                Sharma, N and Gupta, V ( 2021). Therapeutic Communication. https://www.statpearls.com/articlelibrary/viewarticle/127665/?utm_source=pubmed&utm_campaign=reviews&utm_content=127665#

                Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care(8th ed.). Philadelphia: Wolters Kluwer Health.

                Wilson, S., Giddens, J., (2013). Health assessment for nursing

                License

                Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.