3: The Health History
- Page ID
- 48098
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- 3.1: Health History Introduction
- To collect detailed information about a patient’s human response to illness and life processes, nurses perform a health history. A health history is part of the Assessment phase of the nursing process.
- 3.2: Health History Basic Concepts
- This page describes the communication process the nurse uses to collect subjective and objective patient data. It is vital to establish rapport with a patient before asking questions about sensitive topics to obtain accurate data regarding the mental, emotional, and spiritual aspects of a patient’s condition.
- 3.3: Components of a Health History
- This page lists the components of the health history. Each area is further defined and discussed in the following sections.
- 3.4: Demographic and Biological Data
- Demographic and biographic data includes basic characteristics about the patient, such as their name, birthdate, and allergies.
- 3.5: Reason for Seeking Health Care
- It is helpful to begin the health history by obtaining the reason why the patient is seeking health care in their own words.
- 3.6: Current and Past Medical History
- Assessment of the patient's current and past medical history is discussed in this section.
- 3.7: Family Health History
- Many diseases have a genetic component. It is important to understand the risk and likelihood of a patient developing illnesses based on their family health.
- 3.8: Functional Health and Activities of Daily Living
- Information obtained when assessing functional health provides the nurse a holistic view of a patient’s human response to illness and life conditions. It is helpful to use an assessment framework, such as Gordon’s Functional Health Patterns, to organize interview questions according to evidence-based patterns of human responses.
- 3.9: Review of Body Systems
- A body system review asks focused questions related to overall health status and each body system.
Thumbnail: Medical History Form. (CC BY 2.0; Marco Verch via Flickr)