Health History And Documentation - Lake

Trisha Economidis, MS, ARNP
Lake-Sumter Community College
What is a Health History?
 Part of a comprehensive nursing
 Subjective data
 Your Patient’s Story
Interviewing Techniques
 Maintain privacy/confidentiality
 Establish rapport/trusting relationship
 Provide a comfortable environment
 Communicate
Communication Tips
 Open posture at eye level with patient
 Limit distractions
 Don’t take excessive notes
 Beware of biased questions
Conducting the Interview
 Directive vs. Nondirective questioning
 Nurse listens, clarifies, and summarizes to
be sure story has been heard correctly
 Validate if you have questions or need more
 When ending the interview: summarize,
give the patient a chance to add
information, leave them as comfortable as
Interviewing Considerations
 Cultural Considerations
 Touch
 Eye contact
 Space
 Time
 Silence
Interviewing Considerations
 Developmental/Age Considerations
 Infants
 Toddlers
 Preschoolers
 School age
 Adolescents
 Adults
 Older Adults
Elements of the Health History
 Basic Patient Information
 Chief Complaint
 History of the present illness
 Past Health History
 Family History
 Social History
 Review of Body Systems
Basic Patient Information
 Name
 Date of birth
 Age
 Ethnic background
 Marital status
 Address and Phone number
 Primary care physician
 Emergency contact
Chief Complaint
 Why the patient is seeking health care
 Record the chief complaint in the
patient’s own words in quotation marks
 Ex. “I’ve had chest pain since early this
History of Present Illness
 Onset…..Duration……Location of symptoms
 Setting
 Severity
 Precipitating factors
 Alleviating factors
 Aggravating factors
 Associated symptoms
 Treatments
 Patient’s view of the cause of the symptoms
Past Health History
 Childhood illnesses
 Immunizations
 Previous injuries
 Chronic medical conditions
 Previous hospitalizations
 Previous surgeries and procedures
 Obstetric History
Past Health History, cont.
 Sexual History
 Allergies
 Current Medications……prescription, OTC,
herbals, vitamins, home remedies
 Last exam date
 Behavioral or Mental Health issues
 When documenting subjective data for
the cardiovascular system the nurse
would include which of the following?
 A. Vital signs
 B. Peripheral pulses
 C. Chest pain
 D. Heart sounds
Correct Answer: C
 Subjective data includes any information
that the client experiences, such as
perceptions of pain and other sensations
within the body. Subjective data is that
which can only be related to the nurse by
the client. Vital signs, peripheral pulses and
heart sounds are part of the objective data
that the nurse identifies.
 A client is admitted for evaluation of upper
gastrointestinal symptoms. The nurse
would document which statement as
objective data in the client’s medical record?
 A. Client states, “I have a headache.”
 B. Client states, “I had chicken pox as a
 C. Client has distended abdomen and active
bowel sounds.
 D. Client states, “I feel nauseated after
Correct Answer: C
 Objective data is information that the
nurse can directly obtain and verify.
The nurse can observe distention and
active bowel sounds.
Family History
 Looking for risks for disorders with a genetic or
familial tendency
 Parents, siblings and grandparents
 Genogram will give you a visual representation:
 Current age of each person who is alive
 Age at death and cause
 Any disorders, physical or mental, that may have
genetic link
Social History
 Educational history
 Occupation (think work-related health
 Religious, spiritual and cultural beliefs
 Living conditions
 Support systems
 Significant stressors
 Tobacco, Alcohol and Recreational drug use
 The nurse is gathering present health
practices data while taking a health
history of a client admitted for back
surgery. The nurse asks the client
about alcohol use. The client angrily
asks, “Why do you need to know?”
What is the nurse’s best response?
 A. “If you consume alcohol then I will need
to provide alcohol counseling.”
 B. “I need to know because alcohol can
interact with many medications.”
 C. “You are very defensive and this suggests
you probably have an alcohol problem.”
 D. “I can make a referral to alcohol self-help
groups for you.”
Correct Answer: B
 Alcohol is a substance that may worsen
many medical conditions and also interact
with medications. Just because a client
consumes alcohol does not mean that the
client has an alcohol abuse problem or
needs a referral for counseling or a self-help
Review of Body Systems
 Subjective data obtained from the
patient – NOT your physical exam
 Current or past problems
 Asking about common symptoms in a
head to toe fashion
 A nurse is collecting data for an admission
nursing history. Which question by the
nurse is best to open the discussion?
 A. What concern has brought you to the
 B. Would it help to discuss your feelings?
 C. Do you want to talk about your concerns?
 D. Would you like to talk about why you are
Correct Answer: A
 Rationale: This is an open-ended
statement that invites the patient to
communicate while centering on the
reason for seeking health care
 What is the nurse doing when using the
interviewing technique of “active listening?”
 A. Identifying the patient’s concerns and
exploring them with “why” questions.
 B. Determining the content and feeling of
the patient’s message
 C. Employing silence to encourage the
patient to talk
 D. Using nonverbal skills to display interest
Correct Answer: B
 Rationale: Active listening is the use of
all the senses to comprehend and
appreciate the patient’s verbal and
nonverbal thoughts and feelings.
 Which are the most important nursing actions
when speaking with an older adult whose hearing
is impaired? Select all that apply.
 A. Limit background noise
 B. Exaggerate lip movements
 C. Raise the pitch of your voice
 D. Stand directly in front of the patient when
 E. Raise the volume of your voice while speaking
directly toward the patient’s good ear.
Correct Answers: A & D
 Rationale:
 A: Limiting competing stimuli promotes reception of
verbal messages
 D: This focuses the patient’s attention on the nurse. A
hearing-impaired receiver must be aware that a
message is being sent before the message can be
received and decoded.
 When responding to questions asked during
a review of systems the client reports having
a sore throat, which “happens all the time.”
The nurse should ask which question next?
 A. “When did this sore throat begin?”
 B. “What do you mean you have sore throats
all the time?”
 C. “Did you also have sore throats as a
 D. “Did you ever take antibiotics?”
Correct Answer: A
 Knowing when the sore throat began may
provide information as to whether it
coincides with event, allergy, or illness.
Option B sounds argumentative and is not
therapeutic. Option C does not obtain
useful information as children commonly
have sore throats. Asking if he or she ever
took antibiotics will not yield info about
current medication use or info about the
current sore throat.
 Act of recording patient status and care
 May be in written or electronic forms or
 Record of proof
 Best way to prove accountability
Purpose of Documentation
 Plan and evaluate patient care
 Communication between disciplines
 Legal documentation
 Quality improvement
 Reimbursement
 Education
 Research
Principles of documentation
 Retrievable document
 Accurate, timely
 Effective communication
Documentation Guidelines
 Document as soon as possible
 If written, legible and in black ink
 Only agency-approved abbreviations
 Use patient’s own words in “”
 Use concrete, specific information
 Record objectively – not judgments
 Make sure you are recording in correct client
Guidelines, cont.
 Date, time each entry
 Sign each entry with legal name, credentials
 Don’t leave space between entries
 No erasing, crossing out or correction fluid
 Never change another person’s charting
 Document all phone calls made or received
related to client’s case
Elements of Documentation
 Vocabulary – should use standardized
nursing terminology
 Legibility
 Abbreviations/symbols
 Organization
 Confidentiality
Medical Record Formats
 How the medical record is organized
 Source oriented record systems
 Problem oriented record system
 Charting by exception
 Electronic Health Records (EHR)
Source Oriented Record Systems
 Uses narrative charting
 Organized by different disciplines
 Drawback: Documentation for specific
problem can be fragmented throughout the
Problem oriented record system
 Focus is on patient’s problems or diagnoses
 4 sections:
 Database
 Problem List
 Plan of care
 Progress note
Charting by exception
 Both a format and a system of charting
 Nurse documents ONLY deviations from
pre-established norms
 Uses flow sheets that have standard
assessments documented and then nurse
makes entry when something is outside the
 Drawback: Can lead to lazy nursing
Electronic Health Records
 Recorded via computer
 May be source-oriented or problem-
oriented or a combination of the two
 See pages 296, 297
Systems of Charting
 Types of charting used with the medical
 Charting by exception
 Narrative charting
 PIE charting
 Focus charting (DAR)
Narrative Charting
 Story format
 Describes the patient’s status, interventions
& treatments; and patient’s response.
 Very time consuming and difficult to find
 May be good choice in emergency
situations….simple, chronological order.
Narrative charting example
Smith, John Patient No. 261815
9/25/12 1800
Patient complaining of pain stating “my side is killing me.”
Rates pain as a 7 on a scale of 1-10. Patient medicated with
Percocet, two tabs p.o. and repositioned for comfort. P. Smith, R.N.
Patient now rates pain as a 2 on a scale of 1-10. Presently ambulating in
hallway. P. Smith, R.N.
PIE Charting
 Problem
 Intervention
 Evaluation
 Each problem labeled and numbered
 Nursing notes correspond to the problem #
 Each to use and find info
 Disadvantage: Doesn’t document planning
portion of nursing process
PIE Charting example
Smith, John
Problem List
1. Altered comfort level
2. Altered skin integrity
9/25/12 1800 #1P: Patient states “my side is killing me.” Rates pain at RUQ incision
as a 7 on a scale of 1-10. P. Smith, R.N.
1810 #1I:
1850 #1E:
Patient medicated with Percocet, two tabs p.o. and repositioned for
comfort. P. Smith, R.N.
Patient rates pain as 2 on a scale of 1-10. Presently ambulating in
hallway. P. Smith, R.N.
 S – Subjective data
 O – Objective data
 A – Assessment : Conclusion reached – Diagnoses
 P – Plan: Short and long-term goals/strategies for
 I – Interventions: Actions performed to achieve
 E - Evaluation: Effectiveness of interventions
 R – Revision: Changes made to original plan
SOAPIE Example
John Smith
1800 S: “My side is filling me.”
O: Patient guarding RUQ incision site. Rates pain as 7 on a scale of 1-10.
A: Alteration in comfort related to surgical incision.
P: Medicate as needed per physicians order. Provide comfort measures. P. Smith, RN
1810 I: Patient medicated with Percocet, 2 tabs, po and repositioned for comfort.P.Smith RN
1850 E. Patient rates pain as 2 on a scale of 1-10. Presently ambulating in hallway.P Smith RN
Focus Charting
 Not limited to problems, but also patient concerns
as well.
 Way of organizing narrative charting
 DAR Format
 D – Data : Subjective & objective
 A – Action – Actions or nursing interventions
 R – Response – Evaluation of interventions or how
the patient responded
Focus Charting – DAR example
John Smith
1800 Altered comfort level
related to surgical
D: Patient states “my side is killing me.” Patient observed
to be guarding RUQ incision site. Rates pain as 7 on a scale
of 1-10. P. Smith RN
A: Patient medicated with Percocet, 2 tabs po. Patient
assisted with repositioning. Dressing on RUQ incision site
observed to be clean, dry and intake. P. Smith, RN
R: Patient rates pain as a 2 on a scale of 1-10. Presently
ambulating in hallway with family members. Observed to
be standing erect and walking without the assistance of
family members.
 The nurse documents that the client has
crackles bilaterally in the lower lobes of the
lungs after completing a flow sheet for other
assessment data. What format of
documentation is this nurse most likely
 A. Narrative notes
 B. SOAP notes
 C. Charting by exception
 D. PIE notes
Correct Answer: C
 Charting by exception uses a flow sheet of
established standards or normal parameters
and the nurse only documents finding
outside the normal parameters.
 Crackles in the lungs would be an abnormal
Other nursing documentation
 Nursing admission assessment
 Graphic flow sheets
 Medication administration records
 And others…..
 Also must give handoff reports
 SBAR – format for framing reports, conversations with
other disciplines
 S – Situation: State your name, unit, patient’s name,
room #, and the problem.
 B – Background – circumstances leading up to the
situation, i.e. lab results, current symptoms
 A – Assessment – state problem or what you think is
causing it (make an inference)
 R – Recommendation – State what you think will
correct the problem or what you need from the
SBAR example for calling HCP
S – This is Pat Smith from 3S. I’m calling about Mr. Tony Andrews in Room 321. Mr. Andrews is
Very confused, crawling over the bed rails and yelling unintelligibly.
B – I gave him the first dose of Demerol 50 mg iv that was ordered for pain 2 hrs ago at 2000.
A – Day shift nurse reported that he was very cooperative and his conversation/behavior was
appropriate. The family denies any history of “sundowning” behavior. I believe his confusion
and unsafe behaviors are related to the Demerol.
R – Recommendation – I would like to have an order for soft wrist restraints until he is
cognizant of his behavior. Also I would like to try a different pain medication.
 When orienting a new nurse to a hospital
unit, the nurse preceptor would reinforce
which principles of appropriate
documentation in the client record? Select
ALL that apply.
 A. Accurate
 B. Complete
 C. Computerized
 D. Confidential
 E. Completed according to professional
Correct Answers: A, B, D, E
 Crucial elements of documentation are
accuracy, completeness, maintaining
confidentiality, and completion
according to standards. Whether it is
computerized or not is a health systems
choice rather than a principle of
 After the nurse gathers health assessment
data on a client admitted with pneumonia,
the nurse would take which action?
 A. Review the information gathered to
analyze the data
 B. Report all findings to the healthcare
 C. Schedule an interdisciplinary planning
 D. Develop appropriate client goals for
identified problems.
Correct Answer: A
 The nurse analyzes the data and then plans
care for the client. Only abnormal findings
are reported to hcp. Interdisciplinary care
planning meetings are a team approach to
developing a plan of care. Goals are
developed to address health problems found
on assessment once the nurse has
completed the analysis phase of the nursing
process, which leads to nursing diagnoses.

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