Home > Encyclopedia of Nursing & Allied Health > Health History

Definition

The health history is a current collection of organized information unique to the individual patient. Relevant aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, and spiritual data.

Purpose

The history aids the patient and health care provider by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between patient and medical professional. The information also helps determine the patient's baseline, or what is normal and expected for the patient.

Description

The clinical interview is the most common method for obtaining a health history. When the patient or a designated representative of the patient can communicate effectively, the clinical interview is a valuable means of soliciting information.

The information that comprises the health history may be obtained from the patient's previous records, the patient, or in some cases the patient's significant others or caretakers. The depth and length of the history-taking process is affected by factors such as the purpose of the visit, the urgency of the complaint or condition, the patient's willingness or ability to contribute information, and the environment. When circumstances allow, a history may be holistic and comprehensive, but at times only a cursory review of the most pertinent facts is possible. In cases where the history-gathering process needs to be abbreviated, the history focuses on the patient's medical experiences.

Health histories can be organized in a variety of ways. Often an organization such as a hospital or clinic will provide a form or computer database that serves as a guide and documentation tool for the history. Generally the first aspect covered by the history is identifying data.

Identifying data includes facts such as:

• name
• gender
• age
• date of birth
• occupation
• family/social situation

• source of referral

Once the identifying data is collected, the history addresses the reason for the current visit in expanded detail. The reason for the visit is sometimes referred to as the chief complaint or the presenting complaint. Once the reason for the visit is established, additional data is solicited by asking for details that provide a full picture of the current clinical situation. For example, in the case of pain, aspects such as location, duration, intensity, precipitating factors, aggravating factors, relieving factors, and associated symptoms would need to be recorded. The full picture or "story" that accompanies the chief complaint is often referred to as the history of present illness (HPI).

The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the patient's current and past medical experiences that follows a head-to-toe pathway.

The names for categories in the review of systems may vary but generally consist of variations on the following list:

• head, eyes, ears, nose, throat (HEENT)
• cardiovascular
• respiratory
• gastrointestinal
• genitourinary
• integumentary
• joint/muscular
• endocrine
• central nervous system (includes psychiatric)

An orderly and thorough review of systems is often completed by asking the patient about each system in a head-to-toe fashion, moving from current to past and from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the patient's current condition.

Past and current medical history includes details on medicines taken by the patient, as well as allergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to toxins or carcinogens, and health maintenance habits such as self breast examination or immunizations.

An example of a line of questioning might be:

• How are your ears?
• Are you having any trouble hearing?
• Have you ever had any trouble with your ears or with your hearing?

If the patient indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to their current or past condition.

In addtion to identifying data, chief complaint, and review of systems, a comprehensive health history also includes factors such as the patient's family and social life, family medical history, mental or emotional illnesses or stressors, detrimental or beneficial habits such as smoking or exercise, and aspects of culture, sexuality, and spirituality that are relevant to the individual patient. The clinician also tailors his or her interviewing style to the age, culture, educational level, and attitudes of the patient whom they are interviewing.

Preparation

Because the information obtained from the interview is subjective, it is important that the interviewer assess the patient's level of understanding, education, communication skills, potential biases, or other information that may affect accurate communication. Thorough training and practice in techniques of interviewing such as asking open-ended questions, listening effectively, and approaching sensitive topics such as substance abuse, domestic violence, or sexual practices assists the clinician in obtaining a maximum amount of information without upsetting the patient or disrupting the interview. The interview should be preceded by a review of the chart and an introduction by the clinician. The clinician should explain the scope and purpose of the interview and provide privacy for the patient. Others should only be present with the patient's consent.

Health care team roles

Physicians, physician assistants, nurses, nurse practitioners, and many allied health professionals are trained to obtain a patient's health history. The clinician primarily responsible for this task may vary according to the clinical setting.

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KEY TERMS

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Holistic—Pertaining to all aspects of the patient, including biological, psychosocial, and cultural factors.

Subjective—Influenced by the perspective of the information provider; potentially biased.

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Katherine Hauswirth, APRN