When collecting data on the history of the present illness, it is appropriate to include what?

NDNP 819 - Advanced Health Assessment Across Lifespan

Module: History Data, Clinical Reasoning

History Components

History Data Collection Overview

Subjective data are what the patient or family tells you. These data belong in the history section of documentation while objective information is what the provider sees, smells, feels and hears. This information is recorded in the physical exam section.

Subjective information is collected and in a sequential manner.

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Medications/Allergies Past Medical History (PMH)
• Health Maintenance (HM) Family History (FH)
• Social History (SH) Review of Systems (ROS)

Chief Complaint & History of Present Illness

Chief Complaint (CC):

The chief complaint (cc) directs the purpose of the encounter. The APN can ask the question “What brings you here today?” to get this information from patients. When documenting the chief complaint, use the patient’s or family member’s actual words whenever possible. For example, “My throat hurts” would be an appropriately documented chief complaint.

History of Present Illness (HPI):

The HPI obtains specific information about the chief complaint. OLDCARTS is an acronym to assist in collecting these details and preferred method for documentation for billing purposes

• Onset—“When did it begin”?
• Location—“Where is it located?”
• Duration---“How long does it last?”
• Character—“What does it feel like?”
• Alleviating/aggravating—“What makes it better?” “What makes it worse?”
• Radiation—“Does it present in other areas?”
• Timing---“Does it happen in the daytime? Nighttime? Is it continuous?”
• Severity---“How bad is it for you?”

It is also important to assess for ASSOCIATED SYMPTOMS; symptoms that can coexist with the chief complaint. The APN must explore symptoms and physical findings of disorders. E.g. dizziness could be cardiac, vascular or labyrinth problems.

HPI is documented in short paragraph form:

HPI: 45 y.o. male presents with a 2-day rash located on his trunk and abdomen. Reports pruritus since it began and lasts all day. The pruritus has worsened in severity. No other noted rashes on any other parts of his body. Denies pain, fever, chills or recent illness. Denies new soaps or detergents or exposures to environmental allergens.

Medications and Allergies

Full documentation of medications include prescribed, over the counter, supplements and vitamins with doses and frequencies. It’s important to NOT assume the medications have been taken as prescribed. One question to ask would be “How many doses have you missed this week?” assumes that it’s a frequent issue (it is) so it allows the patient to answer freely.

Allergies are anaphylaxis, trouble breathing or rash. Side effects such as nausea, diarrhea, vomiting, etc. are not allergies, rather medications to avoid in the future. Document all medication, food and environmental allergies with reaction. If patient reports an allergy, ask, “What happened when you took this medication?”

Document medications and allergies:

Meds: Metformin 1000mg daily; Lipitor 40mg daily (sometimes misses 1-2 doses/week). No OTCs, vitamins or supplements

Allergies: Sulfa-rash, no food or environmental allergies

Past Medical History, Health Maintenance, Family History

Past Medical History (PMH):

This section includes all past incidences of serious illnesses (childhood and adult), hospitalizations, transfusions, OB/GYN if applicable, mental health history and surgeries.

Use precise wording for documenting past surgeries and rationales: For example, hysterectomy itself is insufficient—Simple hysterectomy (uterus alone) versus hysterosalpingo-oophorectomy (includes ovaries and tubes) gives appropriate information for diagnostic and treatment options. Was it cancer, endometriosis, menorrhagia etc.?

Health Maintenance (HM)

This category includes diet, exercise patterns; sleep quality, caffeine use, age appropriate screenings and immunizations. Click link on the module landing page to review the CDC Adult Immunization Schedule and the USPSTF Clinical Prevention Recommendations.

Collect quantitative data�how much do you exercise? How much coffee, teas and sodas do you drink a day? Document dates of immunizations and screenings and if screening was negative or positive.

Family History (FH):

The history includes three generations (mother, father, siblings, grandparents, children). You must document if they are alive or deceased, their age and medical problems. If someone in the family had a myocardial infarction, record the person’s age since it highlights a significant risk factor for the patient. It also helps to conduct a general survey of family history at the beginning so important disorders and diseases can be identified in the family.

“Is there any diabetes, hypertension, dyslipidemia, heart disease, cancers, mental health, substance abuse in the family?”

Documentation for a 50 year old female:

PMH:   Childhood Illnesses: Varicella age 8, Adult Illnesses: DM for 10 years, HTN, Hospitalizations: none, Surgeries: Appendectomy age 35 (infection), Transfusions: none, OB/GYN: G4 P4 LMP-2 weeks ago, Mental illness: none

HM: Diet: eats three main meals/day with carbohydrate snacks. Avoids vegetables. Exercise: none. Sleep: 7 hours/night-feels rested. Caffeine: 4-16 oz coffees/day. Screenings: Last pap: 2015-negative. Mammogram: 2015-negative. Colonoscopy: never. Immunizations: DTap 2014. Hep B series completed 1992. Influenza: Fall 2016.

FH:  Mother (M) Alive 75 –DM, arthritis; Father (F) deceased at age 55 DM, HTN, CHF. No Siblings. MGM deceased 80s -DM, MGF deceased 60s-unknown, PGM and PGF-no known history. Children: son age 24 A&W. No known cancers, mental health or substance use disorders in the family.

Social History And Review Of Systems

Social History (SH):

Record in outline form the person’s occupation, education, and family situation ("Who do you live with? Do you have a partner? Do you have any concerns about your sexuality, sexual orientation, or sexual desires?"). Ask about violence exposure:

• "Do you feel safe in your home, school and work? Do you have any guns?"

Substance Use: Normalizing questions about substance use can yield more honest answers. “Do you drink?” is an easy yes/no question; instead “How much do you drink?” would give you quantitative information “What size of a drink?”’ Common answers are “socially”—have the patient define “socially”—is that weekly, monthly? How many drinks at one time?” Always ask about non-medical use of prescribed medications (stimulants, opioids for example), recreational drug use (cannabis too), and tobacco use.

Review of Systems (ROS):

The ROS are screening questions: �Do you have these symptoms in the last month?� Ask at least three ROS questions per system for a complete physical exam or cover appropriate ROS sections based on a focused exam. If a question or system was covered in the HPI, write �per HPI�. If a patient reports a �yes�, then complete a HPI on that symptom. A pertinent positive is a sign or symptom is important to explore. A pertinent negative suggests the APN may not need to explore that sign or symptom further.

Document SH and ROS:

SH: Education: High School. Occupation: Bus Driver. Family Situation: Living with girlfriend. No concerns about violence. Substances: Tobacco: none. Alcohol (ETOH): 1-2 12 oz beers/night. Drugs: none.

ROS: General: No fever, chills or weight changes, Skin: No rash, pruritus, or mole changes, HEENT: No headaches, head trauma, hair loss, eye pain, discharge or blurred vision, ear pain, discharge or hearing difficulties, nasal congestion, rhinitis, or nose bleeds, no frequent sore throats, dysphagia or mouth lesions, Neck: no pain, stiffness or swelling, Breasts: no masses, nipple discharge or dimpling, Respiratory: no SOB, frequent cough or nocturnal orthopnea, CV: no CP, palpitations or DOE, GI: no N/V/D/C, abdominal pain or regurgitation, GU: no discharge, polyuria or pain, PV: no pain, varicosities or edema, MS: no pain, stiff joints or swelling, Neuro: no seizures, numbness/tingling in extremities, or gait imbalance, Heme: no easily bruising, fatigue, pale tongue, Endo: no polydipsia, polyphagia, or hot/cold intolerance, MH: no depressive, anxious or suicidal symptoms

What data is included in a health history?

How do you take a good history of present illness?

Which data should be included in a health history quizlet?

What would be important information to collect in the health history?