As you gain experience assessing patients in different settings, you will find that new patients in the office or in the hospital merit a comprehensive health history; however, in many situations a more flexible focused, or problem-oriented, interview may be appropriate. Like a tailor fitting a special garment, you will adapt the scope of the health history to a number of factors: the patient's concerns and problems; your goals for assessment; the clinical setting (inpatient or outpatient; specialty or primary care); and the amount of time available. Knowing the content and relevance of all components of the comprehensive health history allows you to choose those elements that will be most helpful for addressing patient concerns in different contexts.
The components of the comprehensive health history structure the patient's story and the format of your written record, but the order shown here should not dictate the sequence of the interview. Usually the interview will be more fluid and will follow the patient's leads and cues, as described in Chapter 2. Each segment of the history has a specific purpose, which is summarized below.
These components of the comprehensive adult health history are more fully
^described in the next few pages. The comprehensive pediatric history appears in Chapter 17. These sample adult and pediatric health histories follow stan-
Components of the Health History
Reliability Chief Complaint(s) Present Illness
Personal and Social History
Review of Systems
■ Identifying data—such as age, gender, occupation, marital status
■ Source of the history—usually the patient, but can be family member, friend, letter of referral, or the medical record
■ If appropriate, establish source of referral, since a written report may be needed.
Varies according to the patient's memory, trust, and mood
The one or more symptoms or concerns causing the patient to seek care
■ Amplifies the Chief Complaint, describes how each symptom developed
■ Includes patient's thoughts and feelings about the illness
■ Pulls in relevant portions of the Review of Systems (see below)
■ May include medications, allergies, habits of smoking and alcohol, since these are frequently pertinent to the present illness
■ Lists childhood illnesses
■ Lists adult illnesses with dates for at least four categories: medical; surgical; obstetric/ gynecologic; and psychiatric
■ Includes health maintenance practices such as: immunizations, screening tests, lifestyle issues, and home safety
■ Outlines or diagrams of age and health, or age and cause of death of siblings, parents, and grandparents
Describes educational level, family of origin, current household, personal interests, and lifestyle
Documents presence or absence of common symptoms related to each major body system
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