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Health History Advanced Health
assessment
name, gender, age, ethnicity, occupation, source of referral, date and time of the encounter Patient identifiers Patient child complaint Must be written in quoted as the patient said History of present illness Amplifies the patient chief complaint childhood illnesses, major adult illnesses and conditions, allergies, medications, injuries, hospitalizations, transfusions, immunizations, screening exams, psychiatric mental health. What should include the past medical history major illnesses and health status of relatives, mother, father and grand parents, siblings, cause of death. What should include the family history personal data, occupation, housing, safety, social economic status, diet, exercise, sleep, sexual history, drug and alcohol use, social support, stress and anger management, recreation and travel, cultural beliefs and practices, the spiritual is a comma Military service.
Social history *General-fever,-generalmalaise o Eyes:-Blurryvision,-diplopia o ENT:-Sorethroat,-rhinorrhea,-nosebleeds, o Resp:-cough,-wheezing,-sob, o CV:-syncope,+chestpain o GI:-vomiting,-diarrhea o GU:-dysuria,-hematuria o MSK:-backpain,-jointpain o Skin:-rashes.-lesions What should be included in review of systems? Comprehensive Health History should be for performed on all non-emergent, new patients who will be receiving ongoing primary care from a particular provider or group of clinicians. Focused Health History Is performed in emergency situations and when the patient is already undergoing the care of the clinician and presents due s specific problem OLD CARTS stands for Onset Location Duration
T Client outcomes Timing, including insert, duration and frequency of ssx O Client outcomes Other sx that occurs in the association with the major presenting ssx U Client outcomes Understanding beliefs about the client possible causation of the client illness or condition T Client outcomes Treatment and other therapies that the patient have used to alleviate patient ssx or condition C Client outcomes Complimentary alternative medicine O Client outcomes Options of r care that are important to the patient. (advance Directives) M Client outcomes Modulating factors that precipitate, aggravate, or alleviate the patient's symptoms/condition
E Client Outcomes exposure to infectious agents, toxic materials, etc. S Client Outcomes spirituality, including spiritual beliefs, values, and needs of the patient sidelying position Deffered position for a pregnant lady it is important to look carefully before touching. Inspecting without disturbing the baby is the key period visual assessment provides many clues in determining the diagnosis. Assessment sequence for newborn should be head or functional, extremities, abdomen, and rested the body. Always save invasive procedures such as otoscopic examination for last. Techniques used in examining neonates Toddler Give a one-year-old and object to hold his hands. With a toddler, Use gentle pad pleasing words or interactive play Children Allow to touch the equipment to use during the examination. For example, allow to use this telescope to listen to his favorite heart.
Validation Provided verbal support that legitimizes the patient emotional experience Reassurance Avoid premature or false re-assurance. The first step in effective reassurance is identifying and accepting the pt feelings without offering reassurance at the moment. Empowering the patient The clinician - patient relationship is inherently unequal. Patients have many reasons to feel vulnerable. Ultimately patient must be empowered to take to take care of themselves and follow through on your advise. Tell patient when you are changing directions during the interview. Given the patient greater sense of control. Transitions Summarization Giving a capsule summary lets the patient know that you have been listening carefully. Partnering express your desire to work with patient in an ongoing way.
- Active listening
- Empathic responses
- Guided questioning
- Nonverbal communication
- Validation
- Reassurance
- Partnering
- Summarization
- Transitions
- Empowering the patient Techniques of skilled interveiwing Why is Motivational interviewing important
- May help the patient achieve desire behavior
- This makes assumptions that patients know what is best for them and helps them to confront their ambivalence to change.
- Ask open-ended questions – invite pt to consider how and why they might change.
- Listen to understand your pt experience - Show empathy and encourage the pt to elaborate
- Inform – Ask permission to provide information and what the implications might be. How is motivational interviewing done? The way people perceive, interpret and respond to illness.
SHAMP
S- Speech pattern H- Hearing impairment A- Appearance M- Mobility P - Physical structure State of health o Levelofconsciousness o Anysignsofdistress o Skincolorandobviouslesions o Dress,groomingandpersonalhygiene o facial expression o Anyodors, breath o Motoractivityandgait o Heightandweight o Posture o o Mannerandaffect o Reactions to persons and things in the environment o Listen to the patient manner of speaking note the state of awareness or level of consciousness What to include in general surveys Observe for pace, range, character, appropriateness of movements
What to observe in patient behavior
