What information should you obtain when taking a thorough history on a patient?
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The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). Show Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The hospital will have a form with assessment questions similar to the ones listed in Checklist 16. Disclaimer: Always review and follow your hospital policy regarding this specific skill.StepsAdditional InformationDetermine the following:1. Biographical data
When taking a medical history from a client it is very important to phrase your questions correctly. Asking, "Does Fred drink a lot of water?" is leading the client, and possibly in the wrong direction. Just as when you are performing a physical examination, your job is to collect as much information as possible and asking questions in the same order every time will lead to a complete history. You should always review the patient's chart prior to meeting with the client. If possible it is a good idea to read through at least the last year of visits. That can seem like a lot of information but there are many times when a DVM suggested a diagnostic test that has somehow been missed or a phone message the client never received. Our job is not to let anything slip by. Review the patient's problem list, vaccine history and last blood work performed and look at the blood results. By reviewing these you will know what to discuss with the owner. Review the signalment; age, species/breed, gender/altered. Know not just the patient's and client's names but how to pronounce them prior to entering the exam room. When entering the exam room be sure to introduce yourself to the client and the patient. If you already know the client, a sincere greeting and a few cordial words prior to taking the history will most likely put the client at ease which will make your job easier. The following questions may seem unnecessary to the client, especially if the pet is ill, but take a few moments to explain the importance to the client. You need to consider the reason the pet is being seen and collect all the information needed to immediately treat the patient, but at some point you will need to have all the questions answered. The questions that follow should be asked at any visit, well or sick; additional questions below are indicated only for sick visits. Keep in mind it is not possible for us to touch on every illness or injury a patient will present for in this article. It is a good idea when taking a history to use a checklist; this is a great way of making sure we do not forget anything. What are the four components of a patient history?Past medical history (PMHx) Drug history (DHx) Family history (FHx) Social history (SHx)
What information must be included in the history and physical examination?It includes the patient's age, gender, most pertinent past medical history and major symptoms(s) and duration. Whenever possible, this statement should identify the significant issue from the patient's perspective, and include the patient's words if the patient accurately represents the reason for the presentation.
Which vital information will you collect from the client during history taking?History of presenting complaint, including investigations, treatment and referrals already arranged and provided. Past medical history: significant past diseases/illnesses; surgery, including complications; trauma. Medication history: now and past, prescribed and over-the-counter medicines, allergies.
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