During a health history, the nurse collects subjective data from the patient, their caregivers, and/or family members using focused and open-ended questions. Before discussing the components of a health history, let’s review some important concepts related to assessment and communicating effectively with patients. Obtaining a patient’s health history is a component of the Assessment phase of the nursing process. Information obtained while performing a health history is called subjective data. Subjective datais information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance. Subjective data is considered a symptom because it is something the
patient reports. When documenting subjective data in a progress note, it should be included in quotation marks and start with verbiage such as, “The patient reports…” or “The patient’s wife states…” An example of subjective data is when the patient reports, “I feel dizzy.” A patient is considered the primary source of subjective data. Secondary sources of data include information from the patient’s chart, family members, or other
health care team members. Patients are often accompanied by their care partners. Care partners are family and friends who are involved in helping to care for the patient. For example, parents are care partners for children; spouses are often care partners for each other, and adult children are often care partners for their aging parents. When obtaining a health history, care partners may contribute important information related to the health and needs of the
patient. If data is gathered from someone other than the patient, the nurse should document where the information is obtained. Objective data is information observed through your senses of hearing, sight, smell, and touch while assessing the patient. Objective data is obtained during the physical examination component of the assessment process. Examples of objective data are vital signs, physical examination findings, and laboratory results. An example of
objective data is recording a blood pressure reading of 140/86. Subjective data and objective data are often recorded together during an assessment. For example, the symptom the patient reports, “I feel itchy all over,” is documented in association with the signof an observed raised red rash located on the upper back and chest. It is vital to establish rapport with a patient before asking questions about sensitive topics to obtain accurate data regarding the mental, emotional, and spiritual aspects of a patient’s condition. When interviewing a patient, also consider the patient’s developmental status and level of understanding. Ask one question at a time and allow adequate time for the patient to respond. If the patient does not provide an answer
even with additional time, try rephrasing the question in a different way for improved understanding. If any barriers to communication exist, adapt your communication to that patient’s specific needs. For more information about potential communication barriers and strategies for adapting communication, visit the
“Communication” chapter in Open RN Nursing Fundamentals. Cultural SafetyIt is important to conduct a health history in a culturally safe manner. Cultural safety refers to the creation of safe spaces for patients to interact with health professionals without judgment or discrimination. Focus on factors related to a person’s cultural background that may influence their health status. It is helpful to use an open-ended question to allow the patient to share what they believe to be important. For example, ask “I am interested in your cultural background as it relates to your health. Can you share with me what is important to know about your cultural background as part of your health care?” If a patient’s primary language is not English, it is important to obtain a medical translator, as needed, prior to initiating the health history. The patient’s family member or care partner should not interpret for the patient. The patient may not want their care partner to be aware of their health problems or their care partner may not be familiar with correct medical terminology that can result in miscommunication. Note: This guideline is currently under review. Aim Definition of Terms Process Assess Plan Implement and Evaluate Companion Documents Evidence Table References IntroductionNursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. AimTo provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH. Definition of Terms
ProcessNursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this. Fig 1. Nursing Process
 AssessAt the beginning of each shift, a ‘shift assessment’ is completed as outlined in the Nursing Assessment Guideline. The information for this assessment is gathered from handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’. Review of the EMR gives an overview of the patient. To complete an EMR review, enter the patients’ medical record and work through the key activities in order. These tabs
can be customised to meet the specific needs of your patient group (EMR tip sheet link - coming soon). It is recommended that each ward standardises the layout of their activity bar based on their patient population.
Patient assessments are documented in the relevant flowsheets and must include the minimum ‘required documentation’. To ensure required documentation for each patient is complete, use the summary side bar link (EMR Req Doc tip sheet link -- coming soon). PlanWith the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care. The nursing hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team. Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety. Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift. Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. This may include:
Implement and evaluateProgress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family. All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful. Example of real time progress note entry: Companion Documents
Evidence TableThe evidence table for this guideline can be viewed here. References
Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Natasha Beattie, RN Cockatoo & Lauren Burdett, CNS Platypus and approved by the Nursing Clinical Effectiveness Committee. Updated March 2019. Which documentation would the nurse include in the health history?Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans.
What are 4 components of the health history?In general, a medical history includes an inquiry into the patient's medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
What information is included in a health history?A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
What are 5 components of a health history?Current and past medical history. Family health history. Functional health and activities of daily living. Review of body systems.
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