NSG 6020 Identification of patient and source of history
NSG 6020 Identification of patient and source of history
NSG 6020 Identification of patient and source of history
Included identification of patient and source of history.
Included past medical/surgical history, family history, habits, and social and family history.
Used correct spelling, grammar, and professional vocabulary. Cited all sources using the APA format. No references
Description
The clinical interview is the most common method for obtaining a health history. When a person or a designated representative can communicate effectively, the clinical interview is a valuable means for obtaining information.
The information that comprises the health history may be obtained from a person’s previous records, the individual, or, in some cases, significant others or caretakers. The depth and length of the history-taking process is affected by factors such as the purpose of the visit, the urgency of the complaint or condition, the person’s willingness or ability to contribute information, and the environment in which information is sought. When circumstances allow, a history may be holistic and comprehensive, but at times only a cursory review of the most pertinent facts is possible.
NSG 6020 Identification of patient and source of history – | Nurses Homework
Identifying or basic demographic data includes facts such as:
- name
- gender
- age
- date of birth
- occupation
- family structure or living arrangements
- source of referral
Once the basic identifying data is collected, the history addresses the reason for the current visit in expanded detail. The reason for the visit is sometimes referred to as the chief complaint or the presenting complaint. Once the reason for the visit is established, additional data is solicited by asking for details that provide a more complete picture of the current clinical situation. For example, in the case of pain, aspects such as location, duration, intensity, precipitating factors, aggravating factors, relieving factors, and associated symptoms should be recorded. The full picture or story that accompanies the chief complaint is often referred to as the history of present illness (HPI).
The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person’s current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order.
The names for categories in the review of systems may vary, but generally consists of variations on the following list:
- head, eyes, ears, nose, throat (HEENT)
- cardiovascular
- respiratory
- gastrointestinal
- genitourinary
- integumentary (skin)
- musculoskeletal, including joints
- endocrine
- nervous system, including both central and peripheral components
- mental, including psychiatric issues
Past and current medical history includes details on medicines taken by the person, as well as allergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to chemicals, toxins, or carcinogens, and health maintenance habits such as breast or testicular self-examination or immunizations.
An example of a series of questions might include the following:
- How are your ears?
- Are you having any trouble hearing?
- Have you ever had any trouble with your ears or with your hearing?
If an individual indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to the current or past condition.
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