Foundations of Health History
This type of data is obtained from the patient’s own report.
What is subjective data?
This must always be recorded at the beginning of the health history.
What are the date and time?
The chief complaint should be documented using this.
What are the patient’s own words?
his evaluates how patients manage stress and illness.
What is coping?
Family history identifies risk related to this.
What is genetics?
This data includes findings from physical exams and diagnostic tests.
What is objective data?
Gender identity and this should be documented to promote respectful care.
What are preferred pronouns?
The reason for care should never be documented as this.
What is a diagnosis?
This includes tobacco, alcohol, and marijuana use.
What are personal habits?
This tool visually organizes family health data.
What is a genogram or pedigree?
This combines subjective and objective data to form the patient database.
What is the complete health history?
This helps identify occupational risks and exposures.
What is occupation?
How many critical characteristics are assessed in the HPI?
What are eight?
This assesses support systems and relationships.
What are interpersonal relationships?
Early death in a relative suggests increased need for this.
What is early screening?
This part of the health history is not a one-time event and must be updated.
What is the health history?
This determines whether a medical interpreter is required.
What is primary language?
This HPI characteristic describes onset, duration, and frequency.
What is timing?
This screens for safety and abuse.
What is intimate partner violence?
This distinguishes food allergy from intolerance.
What is the type of reaction?
The health history provides this key benefit before diagnostics are ordered.
What is guidance for clinical decision-making?
This must be documented when someone other than the patient provides history.
What is the source of history?
This HPI characteristic assesses how the symptom affects daily life.
What is the patient’s perception?
These factors often explain non-adherence to treatment.
What are psychosocial factors?
Family history supports these preventive strategies.
What are lifestyle modification and surveillance?