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NURSING HEALTH HISTORY (A Format)
A. Demographic(Biographical Data) (Do not omit the following labels in your output)
- Client’s initials:
- Gender:
- Age, Birthdate and Birthplace:
- Marital(Civil) Status:
- Nationality:
- Religion:
- Address and Telephone Number:
- Educational Background:
- Occupation(usual and present):
- Usual Source of Medical Care:
B. Source and Reliability of Information (Should be in narrative form; you should describe specifically the patient’s attitude during the assessment and their capability of giving accurate and reliable responses)
Sample Statements: The patient was competent to provide information. She was able to speak clearly; conscious and coherent; oriented to time, place and person.
Other Possibilities: The patient was too weak to provide information; data had to be obtained and validated from the relative.
The patient’s chart was also included as a secondary source of information
C. Reasons for Seeking Care or Chief Complaints(Preferably Top 3) (The heading for this section can change according to the data you will obtain, if you get health promotive statements, use only “Reasons for Seeking Care,” if disease-related or complaints, use “Chief Complaints,” if it is a combination, retain the title above then change “or” to “and”)
Sample Statements: (SHOULD BE IN DIRECT QUOTATIONS)
- “Chest pain for 2 hours”
- “Earache and restlessness all night”
- “Physical examination for work purposes”
- “Wants to start jogging and needs check-up”
D. History of Present Illness or Present Health Well person General state of health Ill person Chronological story record of how the illness came about
8 Critical Characteristics: (integrate in one whole narrative)
1. Timing (frequency/onset/duration) 2. Location (the primary area where the symptom occurs or originates) 3. Quality(Character) – (describes the way the cc feels to the patient) 4. Quantity / Severity (volume, number, or extent of the cc) 5. Setting (physical environment, mental state, or activity wherein the symptoms occur) 6. Associated Phenomena / Factors (signs and symptoms that accompany the cc) 7. Aggravating and Alleviating Factors (factors that worsen or decrease the severity of the cc, respectively) 8. Client’s Perception (how the client thinks & feels about the illness)
E. Past Medical History or Past Health (narrative form per category) a. Pediatric / Childhood / Adult Illnesses (Indicate age or date (year) of occurrence) b. Injuries or Accidents (Indicate age or date (year) of occurrence) c. Hospitalization and Operations (Indicate age or date (year) of occurrence) d. Reproductive History (for females – include menstrual history (age at menarche, LMP, cycle and duration), also include OB history (if pregnant: OB score), complications of
pregnancy and birth control methods used, age at onset of secondary sex characterisitics, etc.) (for males: include age at onset of secondary sex characteristics, and any problems or difficulties encountered, etc)
e. Immunization (put a check mark on the following that is applicable to your client) BCG: / / At Birth / / School Entrance DPT: / / 1st^ Dose / / 2nd^ dose / /3rd^ dose OPV: / / 1st^ Dose / / 2nd^ dose / /3rd^ dose AMV: / / TT: / / 1st^ Dose / / 2nd^ dose / /3rd^ dose / / 4th^ dose / / 5th^ dose HBV: / / 1st^ Dose / / 2nd^ dose / /3rd^ dose Others:(Varicella Vaccine? Influenza Vaccine? Pneumococcal Vaccine? etc.)
f. Allergies (put a check mark on the following that is applicable to your client, if the patient has no allergies, just simply indicate “NONE”) / / Food, please specify: _________________________ / / Drugs or medications, please specify: ________________________ / / Chemicals, please specify: _________________________ / / Other environmental allergens, please specify: _________________________
(If there are allergic reactions to any of the allergens listed above, indicate the kind of reaction the patient experiences and intervention used to alleviate the manifestations in a narrative format)
g. Medications (In a narrative format, determine the medications taken by your client prior hospital admission (both prescribed and OTC); indicate the generic and brand name, and if possible, dosage and frequency of intake; do not forget to include the drug’s use or indication based on the patient’s description)
F. Family History (Includes the GENOGRAM; with brief explanation and analysis) (Include age, present condition, cause of death) (Place the “Legend” under the genogram) (If in case the client cannot provide or remember the information, just put “UNRECALLED AGE,” “UNRECALLED ILLNESS,” or “UNRECALLED CAUSE OF DEATH,” whichever are applicable)
Use the following legend:
Male Female Male Patient Female Patient Deceased
G. Socio-Economic History (Include a brief explanation of significant data) (Include the members of the family currently living with the client in the same household; if the client receives financial support from other people, also include them here – just be particular with the relationship of that person to the client)
FAMILY MEMBER / RELATIONSHIP TO PATIENT
OCCUPATION / SOURCE OF INCOME
MONTHLY INCOME (optional)
(Include the patient if he/she is an income earner)
(Write “Not Disclosed” if members prefer confidentiality of income, or N/A if not applicable to the family member)
FUNCTIONAL ASSESSMENT
(Interview Guide)
1. Health-Perception-Health Management Pattern Describes the client’s perceived patterns of health & well- being & how their health is managed.
person’s description of his current health
activities that the person does to improve or maintain his health
person’s knowledge about links between lifestyle choices and health
extent of person’s problem on financing health care, if any
person’s knowledge of the names of current medications he is taking and their
purpose/s
activities that the person does to prevent problems related to allergies, if any
person’s knowledge about medical problems in the family
any important illnesses or injuries in this person’s life
2. Nutritional-Metabolic Pattern Describes the consumption relative to metabolic need & nutrient supply; includes pattern of food & fluid consumption, condition of skin, hair, nails & mucous membranes, body temperature, height & weight.
person’s nourishment
person’s food choices in comparison with recommended food intake
any disease that affects nutritional-metabolic function
3. Elimination Pattern
Describes the pattern of excretory function (bowel, bladder & skin); includes
individual’s daily pattern, changes or disturbances & methods used to control excretion.
person’s excretory pattern
any disease of the digestive system, urinary system or skin
4. Activity-Exercise Pattern Describes the pattern of exercise, activity, leisure, & recreation; includes activities of
daily living, type and quality of exercise & factors affecting activity pattern(such as
neuromuscular, respiratory, & circulatory).
person’s description of his weekly pattern of activities, leisure, exercise and
recreation
any disease that affects his cardio-respiratory and/or musculoskeletal systems
5. Sleep-Rest Pattern Describes the pattern of sleep, rest & relaxation and any aids to change those patterns.
description of the person’s sleep-wake cycle
person’s physical appearance (rested or relaxed?)
6. Cognitive-Perceptual Pattern Describes the sensory-perceptual and cognitive patterns; includes adequacy of
sensory modes(vision, hearing, touch, taste and smell), reports of pain perception,
and cognitive functional abilities.
any sensory deficit and if corrected
person’s ability to express himself clearly and logically
person’s education
any disease that affects mental or sensory function
person’s pain description & causes, if any
7. Self-Perception-Self Concept Pattern Describes how persons perceive themselves; their capabilities, body image and feelings.
anything unusual about the person’s appearance (based on his own description)
if person is comfortable with his appearance
description of the person’s feeling state
8. Role Relationship Pattern Describes the pattern of role engagements and relationships; includes perception of major roles & responsibilities in current life situation.
person’s description of his various roles in life
positive role models of his roles, if any
important relationships at present
any big changes in role or relationship
9. Sexuality-Reproductive Pattern Describes the pattern of satisfaction or dissatisfaction with sexuality; includes female’s reproductive state.
person’s satisfaction with his situation related to sexuality
How have the person’s plans and experiences matched regarding having
children?
any disease/dysfunction of the reproductive system
10. Coping-Stress Tolerance Pattern Describes the general coping pattern and effectiveness of coping skills in stress tolerance.
person’s means/actions of coping with problems
if coping actions help or make things worse
any treatment/therapy for emotional distress (if any)
11. Value-Belief Pattern Describes the pattern of values, goals, or beliefs (including spiritual beliefs) that guide lifestyle choices and decisions.
principles that the person learned as a child which are still important to him
person’s identification with any cultural, ethnic, religious, regional or other
groups
support systems that the person finds significant
jaundice, appendicitis, colitis, flatulence, bowel frequency, any present changes, stool characteristics, constipation, diarrhea, black-tarry stolls, rectal bleeding, rectal conditions (hemorrhoids, fistula), use of antacids and laxatives, also include diet history and substance use
URINARY: Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, UTI, prostate), pain in the flank, groin, suprapubic region, or low back, also include exercise after childbirth
GENITALIA: Male: Penis or testicular exam, pain, sore or lesions, penile discharge, lumps, hernia Female: Any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting, vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, post menstrual bleeding, last gynecological check-up, last papanicolau smear, also include OB history (if married: OB score), complications of pregnancy, birth control methods used and operations undergone
PERIPHERAL VASCULAR: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration of hands or feet (bluish, reddish, pallor, mottling, association with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Does the occupation of the client involve long-term sitting or standing? Does the client avoid crossing legs at the knees? Does the client wear support hose?
MUSCULOSKELETAL: Joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion Muscles: Pain, cramps, weakness, gait problems or problems with coordinated activities Back: Pain (location and radiation to extremities) stiffness, limitation of motion, or history of back pain or disease
NEUROLOGIC: History of seizure disorder and stroke Sensory function: Memory disorders (recent or distant, disorientation) Motor function: tics or tremors, paresis – weakness, fainting, blackouts
HEMATOLOGIC: Bleeding tendency of the skin or mucous membranes, excessive bruising, exposure to toxic agents or radiation, blood transfusions, and reactions
ENDOCRINE: History of diabetic symptom (polydipsia, polyphagia, polyuria) history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, abnormal hair distribution, nervousness, tremors, and need for hormone therapy
PSYCHIATRIC: Nervousness, mood change, depression, history of mental dysfunction or hallucinations
