COMPONENTS OF AHEALTH HISTORYNUR 226Health Assessment
WHY DO WE GATHER DATA?
SUBJECTIVE DATA   Documentation takes many different forms
COMPONENTS OF A HEALTH HISTORY1. Demographic data  a. Name & Address  b. Billing & insurance information  c. Emergency con...
HEALTH HISTORY….
COMPONENTS, CONTINUED4. Past Health History       a. medical diagnoses       b. surgical procedures5. Current medications ...
COMPONENTS, CONTINUED7. Functional Health Assessment       a. self care or activities of daily living       b. checklist8....
COMPONENTS OF A HEALTH HISTORY   Good questioning skills   Open ended questions   Best patient outcome
Health history
Health history
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Health history

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Components of a Health History for the beginning nursing student

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Health history

  1. 1. COMPONENTS OF AHEALTH HISTORYNUR 226Health Assessment
  2. 2. WHY DO WE GATHER DATA?
  3. 3. SUBJECTIVE DATA Documentation takes many different forms
  4. 4. COMPONENTS OF A HEALTH HISTORY1. Demographic data a. Name & Address b. Billing & insurance information c. Emergency contact & religious contact d. Primary language2. Reasons for seeking care a,. Statement in the patients own words3. History of present illness a. Ask additional questions to get more detail b. What makes it worse, what makes it better??
  5. 5. HEALTH HISTORY….
  6. 6. COMPONENTS, CONTINUED4. Past Health History a. medical diagnoses b. surgical procedures5. Current medications and indications for use a. prescriptions: dose, frequency and route b. over-the-counter medcations c. vitamin supplements6. Family History a. health of parents, siblings, children
  7. 7. COMPONENTS, CONTINUED7. Functional Health Assessment a. self care or activities of daily living b. checklist8. Growth & Development a. benchmarks for growth b. psycho-social aspects9. Review of Systems a. head-to-toe list b. cardiac, respiratory, etc
  8. 8. COMPONENTS OF A HEALTH HISTORY Good questioning skills Open ended questions Best patient outcome
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