obtaining a health history

1. Obtaining a Comprehensive
Health History
By: Racheal Paige DNP, MS, ANP-BC

2. Fundamentals of Skilled Interviewing
• Each encounter should follow the sequence of
• 1. Initiating the Session
• 2. Information Gathering
• 3. Physical Exam
• 4. Explaining and Planning
• 5. Closing the Session

3. Fundamentals of Skilled Interviewing
• Engage in active listening
• Sit down!
• Develop a rapport with the patient, start with a non-threatening topic
• Guided questioning
• Watch patient’s non-verbal cues as well as your own
• Use empathetic responses and validate the patient’s feelings
• Empower the patient; ask if there is anything else they would like to tell you

4. Comprehensive vs Focused Health History
• New patients= comprehensive health history
• Patients who present with specific concerns (i.e. a cough or foot pain)=
focused health history
• Established patients who present for their annual physical= comprehensive
health history
• May need a comprehensive health history if the patient presents with a
specific complaint that has numerous differential diagnoses

5. Subjective Information
• This is what the patient tells you, NOT your exam findings or laboratory
data
• History of present illness (HPI) should be entirely subjective
• May include the patient’s feelings and perceptions of symptoms
• Includes chief complaint, HPI, past medical history, past surgical history,
current meds, allergies, social history, family history and review of systems

6. Objective Information
• Includes physical exam findings, laboratory data, diagnostic imaging
• This is information that is not from the patient’s perspective

7. Chief Complaint (CC)
• The term used to describe the primary problem or condition of the patient
prompting the visit
• When documenting the chief complaint, make every attempt to quote the
patient’s own words; ex. “My urine is dark and smells funny”
• If the patient is presenting for an annual check up, the chief complaint
would be “I have come for my annual checkup”

8. History of Present Illness (HPI)
• One of the most important parts of your entire note!!
• It is the chronological description of the problem prompting the visit and
gives clues as to what the diagnosis will ultimately be.
• This is the story of the patient’s presenting complaint
• It is imperative to ask about the presence or absence of additional relevant
symptoms (pertinent positives and negatives)
• Use OLDCARTS!!!

9. What is OLDCARTS?
• O-Onset
• L- Location
• D-Duration
• C- Character
• A- Aggravating or Alleviating Factors
• R- Radiation
• T- Timing
• S- Severity

10. Onset
• “When did the problem first start?”
• “Tell me what you were doing when this started?”
• “Was anything unusual going on in your life when this started?”
• This establishes when the problem started and what the circumstances were.

11. Location
• “Where did your pain start?”
• “Can you point to where the pain is?”
• This establishes where in/on the body the problem, symptom, or pain
occurs.

12. Duration
• “How long does the headache last?”
• “How long are you coughing for?”
• How long the problem, symptom, or pain last.

13. Character
• “Can you describe the pain for me?”
• An adjective describing the type of problem, symptom or pain
• Examples are stabbing, sharp, burning, achy, pressure.

14. Aggravating or Alleviating Factors
• “Does anything make it worse?”
• “Does anything make it better?”
• Actions or activities taken to improve the problem, symptom, or pain and
their outcome
• Document what treatment (medication, heat or cold) the patient has tried to
alleviate the pain and whether it worked.

15. Radiation
• “Does the pain go anywhere”
• Especially important with chief complaint of abdominal pain or chest pain
• Make sure you document “patient denies radiation of pain” if that is true;
any question that is not documented is considered not asked.

16. Timing
• This part of OLDCARTS overlaps with some of the onset questions
• “Is your cough worse in the morning or at night?”
• Any activities that are associated with worsening of pain such as eating a
large meal or exertion

17. Severity
• “On a scale of 0-10, with 10 being the worst possible pain, how would you
rate your pain? At its worst? At its best?”
• “How would you characterize the severity of your shortness of breath- mild,
moderate, or severe?”
• “Overall, has the pain been getting better, worse, or staying the same?”

18. Example of an HPI for Chest Pain
• RB is a 48-year-old male with a past medical history notable for hypertension who
presents the office with a chief complaint of chest pain. He states the chest pain started
2 days ago while he was shoveling snow. He states the pain is in the middle of his chest
and it radiates to his left arm. He characterizes the pain as “it’s like someone is sitting
on my chest.” He states the pain has been constant but worsens if he tries to exert
himself. He tried taking 1000mg of oral Tylenol with no relief. He states the pain is
lessened somewhat by resting. At its worst, the pain is a 6/10, at rest it decreases to
5/10. He denies any fever, cough, shortness of breath, nausea, diaphoresis, palpitations,
or peripheral edema. Patient states his father died of a heart attack at age 50 and he was
afraid to seek treatment because of this.

19. Past Medical History
• Includes all medical problems of the patient whether they are currently active
or remote
• It should include childhood illnesses, adult illnesses
• Sometimes you have to specifically ask if the patient has a history of
hypertension or high cholesterol; some patients are quick to say “I don’t have
any medical problems” and when you look at their med list it tells a different
story.

20. Past Surgical History
• List any surgeries the patient has undergone
• Again, sometimes you have to be direct and specific
• Ask the patient if they still have their tonsils, appendix, gallbladder.
• Ascertain whether the patient has had any issues with surgery (slow to wake
up from anesthesia, blood transfusion reaction)

21. Allergies
• Ask about specific reactions to each medication
• Also ask about allergies to foods, insects, or environmental factors
• An adverse drug reaction is different than an allergic reaction
• Furthermore, a side effect is NOT an allergy

22. Current Medications
• Make sure you include dose, route, and frequency of each medication
• Include OTC and herbal medications
• Encourage the patient to carry an updated medication list
• Will give clues to the patient’s past medical history

23. Family History
• A record of health information about the patient and his or her immediate
relatives
• List ages and health status, age at time of death and cause of death
• Include parents, grandparents, siblings, and children if applicable
• Specifically review premature cardiac death, cancer, stroke, diabetes, lung
disease, hyperlipidemia

24. Personal and Social History
• Captures the patient’s personality or interests, helps to build rapport when you refer
to it for subsequent visits
• May include the patient’s sexual orientation and gender identification, occupation
and education, home environment, military experience.
• ADLs is especially important to document in the older adult’s social history and
caregiver support
• Spiritual and/or religious beliefs would be applicable here
• Include tobacco history, alcohol use, and any current or previous illicit drug use here.

25. Review of Systems
• May uncover problems or symptoms that you or the patient may have overlooked, particularly in areas covered under
the HPI
• Mostly yes-no questions and should come at the end of the interview
• It is helpful to prepare the patient by saying “the next part of the history may feel like a lot of questions, but it is
important to make sure we have not missed anything. I would like to ask you some yes or no questions.”
• If you uncover another symptom, need to explore that symptom using OLDCARTS
• Orient your questioning from head-to-toe
• **Any major symptoms discovered during the HPI which may be related to the chief complaint should be moved to
the HPI in your write up**
• ALWAYS INCLUDE CONSTITUTIONAL REVIEW OF SYSTEMS WHETHER IT IS A COMPREHENSIVE
HEALTH HISTORY OR FOCUSED NOTE

26. NOW WE MOVE TO THE
OBJECTIVE PORTION OF
YOUR HEALTH
HISTORY….

27. Physical Exam
• Make sure you have all necessary equipment and lighting
• Ensure patient privacy and comfort
• Maintain patient modesty
• Give clear instructions
• Keep the patient informed
• When you have completed the examination, consider telling the patient your
general impressions and what to expect next

28. The Physical Exam
• We will go through each system during this course
• You always want to include a general survey which is the observation of the
patient’s general health and build. Note posture, motor activity and gait,
dress, grooming. Listen to patient’s affect and observe their facial motions.
• All comprehensive and focused notes should include a general survey!!
• Always include vital signs under your general survey.

29. The Physical Exam
• The order of the physical exam for each system is inspection, palpation,
percussion, and auscultation.
• The only exception is the abdominal exam which is inspection, auscultation,
percussion, and palpation (do not want to distort bowel sounds with
palpation).
• We will go over in more detail throughout the course.

30. References
Bickley, L. S. (2020). Bates' guide to physical examination and history taking (13th ed.).
Wolters Kluwer.