History Taking
systematic gathering of patient information |
purpose |
build trust |
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identify problem |
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guides care |
skills needed |
professional |
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interpersonal |
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interviewing |
phases of interview |
Introductory |
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Working |
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Termination |
Communications
Nonverbal Communications |
Appearance |
professional look |
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Demeanor |
calm, composed |
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Facial expression |
neautral, attentive |
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Attitude |
respectful |
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Silence |
Verbal Communication |
Open-ended question |
broad; patient explains |
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Close-ended question |
short; specific (yes/no) |
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Barriers of Communication
Distractions |
phone, multitasking |
Too much/little eye contact |
Standing over patient |
feels superios |
Too friendly |
loss of professionalism |
Components of Health History
Biographical Data |
basic personal information |
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used in case studies |
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use initials to protect privacy of patient |
Clinical Data |
reason for seeking care |
chief complaint, date of admission, vital signs, ward, final diagnosis, attending physician (initials), upon admission |
Present Health History |
aspects of health problem |
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detailed description of concern |
symptoms, treatments, precipitating factor, expectation |
Past Health History |
from birth to current age of patient |
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past illnesses/hospitalizations |
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medications/vaccines taken |
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health remedies, health management, clinics, usual medication and maintenance |
Family History (Genogram) |
include as many genetic relatives as client can recall |
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include generations of maternal and paternal lineage |
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include vices |
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include diseases and deceased |
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genogram ends at patient generation |
Psychosocial History |
Lifestyle & Health Practices |
nutrition, exercise, sleep |
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substance use |
specify quantity and name |
Review of Systems |
head-to-toe review, system to system |
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focus on subjective symptoms |
COLDSPA - character, onset, location, duration, severity, pattern, associative factors
always start when onset of sickness started
signs and symptoms over sickness duration
how sickness progressed in the hospital
where patient was admitted
always put sickness if its related to present condition
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