SUBJECTIVE DATA Documentation takes many different forms
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??
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
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
COMPONENTS OF A HEALTH HISTORY Good questioning skills Open ended questions Best patient outcome