Categories of the complete subjective health assessment (as illustrated in Figure 1.4) vary depending on the framework you follow, but generally include:
- Introductory information: Demographic and biographic data.
- Main health needs (reasons for seeking care).
- Current and past health.
- Mental health and mental illnesses.
- Functional health.
- Preventive treatments and examinations.
- Family health.
- Cultural health.
You begin the assessment by collecting information about demographic and biographic data and then, main health needs. Afterwards, there is no specific order in which these categories must be assessed. Often it depends on the client’s main health needs or reasons for seeking care. Sometimes it depends on the natural flow of conversation that occurs with the client. Usually, you assess sections that involve sensitive questions as well as cultural health towards the end when you have had the opportunity to develop a level of trust with the client.
In addition to these categories, you may incorporate subjective questions specific to each of the body’s systems; this phase is called a Review of the Systems. These questions give you insight into each body system (e.g., skin, eyes, cardiovascular, musculoskeletal). Depending on the client’s response and the reporting of cues that prompt your concern, you may probe further with more specific questions. In other readings, you will learn about subjective questions related to each body system.
Always ask one question at a time.
Influencing factors constitute common situational issues that can arise during a subjective data assessment. Always consider factors that may influence how you ask questions and the validity and reliability of the subjective data collected. These situational factors can be difficult to both assess and address in certain cases (see Table 1.2).
Clients may be hyperaware of the situation and wonder why you are asking certain questions.