In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.

1. R.SARAVANAN

2.  History collection is gathering of
information from the patient.
 It is the first step in the providing care
for the patient.
 It is one of the important step in the
diagnosis of the patient condition .
 Through history collection hereditary
disease can be identified and treated.

3. Identification data
Name of the patient :
Age :
Sex :
Identification number :
Bed number :
Ward :
Education :
Occupation :
Monthly income :
Religion :
Nationality :
Chief complaints :
Diagnosis :

4.  Date of admission : on
 Date of care start : on
 Present complaints :
 date of care end : on
 Name surgery :
 Date of surgery : on
 Post operative days :
 Date of discharge : on
Socio economic status :
 Bread winner of family
 Type of family and house
 Monthly income of the family
 Facility of the family like water supply
electricity , ventilation , closed
drainage etc ,,,
 Inter personal relationship with
neighborhood
 Pet animal.

5. Family tree
Keys:
Male Female patient death
Name & age
Name & age
Name & age
Name & age
Name & age
Name & age
s.no name age sex Relationship
With patient
education occupation Monthly
income
Marital
status
Health
status
Family composition

6. Family medical history
 Family history of hereditary disease like
diabetes mellitus or hypertension or any
other hereditary diseases
 History of any communicable disease like
leprosy or tuberculosis
 Or history of any congenital disorder like
cleft lip and palate.
Personal history
 Personal hygiene
Like grooming, bathing, brushing, and
wearing a clean cloths.
 Diet
Belongs to vegetarian or non vegetarian
and Food pattern of the patient.

7.  Sleeping pattern
Sleeping pattern of the patient and
time duration in day and night.
 Elimination pattern
Bowel elimination pattern
Bladder elimination pattern
 Habit
Like smoking and alcohol if it is
present since how many years.
 Hobby
Hobby like reading, writing, watching
TV or playing etc,…
 Allergy
History of food and medicational
allergy for the patient.


8. Medical history
 Present medical history
 Name of the patient,
Date and time of admission,
Hospital name,
Chief complaints,
Diagnostic evaluation,
Ongoing Treatment.
 Past medical history
If presence of past medical history
and reason of past medical history.
Name of the hospital, diagnosis and
treatment details are to be
explained.
If there is no past medical history,
there is no any significant of past
medical history.

9. surgical history
 Present surgical history
› Name of the surgery,
› Name of the surgeon,
› Name of the anesthesia,
› Name of the anesthetist,
› Duration of the surgery,
› Duration of anesthesia,
› No of post operative days are should be
explain.
 Past surgical history
› Name of the surgery,
› Year of surgery,
› Surgery name,
› Any complication of surgery.