What is your primary source of information when obtaining a patient history?

The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).

The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.

Checklist 16: Health History Checklist
Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Steps

Additional Information

Determine the following:

1. Biographical data

  • Source of history
  • Name
  • Age
  • Occupation (past or present)
  • Marital status/living arrangement
2. Reason for seeking care and history of present health concern
  • Chief complaint
  • Onset of present health concern
  • Duration
  • Course of the health concern
  • Signs, symptoms, and related problems
  • Medications or treatments used (ask how effective they were)
  • What aggravates this health concern
  • What alleviates the symptoms
  • What caused the health concern to occur
  • Related health concerns
  • How the concern has affected life and daily activities
  • Previous history and episodes of this condition
3. Past health history
  • Allergies (reaction)
  • Serious or chronic illness
  • Recent hospitalizations
  • Recent surgical procedures
  • Emotional or psychiatric problems (if pertinent)
  • Current medications: prescriptions, over­-the­-counter, herbal remedies
  • Drug/alcohol consumption
4. Family history
  • Pertinent health status of family members
  • Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders
5. Functional assessment (including activities of daily living)
  • Activity/exercise, leisure and recreational activities (assess for falls risk)
  • Sleep/rest
  • Nutrition/elimination
  • Interpersonal relationships/resources
  • Coping and stress management
  • Occupational/environmental hazards
6. Developmental tasks
  • Current significant physical and psychosocial changes/issues
7. Cultural assessment
  • Cultural/health-related beliefs and practices
  • Nutritional considerations related to culture
  • Social and community considerations
  • Religious affiliation/spiritual beliefs and/or practices
  • Language/communication
Data source: Assessment Skill Checklists, 2014

  1. You are taking a health history. Why is it important for you to obtain a complete description of the patient’s present illness?
  2. You are taking a health history. What is one reason it is important for you to obtain a complete description of the patient’s lifestyle and exercise habits?

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  • What is a primary source?
  • What is a secondary source?
  • Secondary Sources
  • What is your primary source of information when obtaining a patient history?
  • Which primary source of information would the nurse use when completing a patient's assessment?
  • What is the nurse's primary source for data collection?
  • What is the primary method of obtaining patient data?

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What is a primary source?

A primary source in science is a document or record that reports on a study, experiment, trial or research project. Primary sources are usually written by the person(s) who did the research, conducted the study, or ran the experiment, and include hypothesis, methodology, and results.

Primary Sources include:

  • Pilot/prospective studies
  • Cohort studies
  • Survey research
  • Case studies
  • Lab notebooks
  • Clinical trials and randomized clinical trials/RCTs
  • Dissertations
  • PubMed This link opens in a new window

    • What is your primary source of information when obtaining a patient history?

      This link opens in a new window

    Major index to articles covering all aspects of medicine.
    Finding Primary Sources: After conducting your search, check the boxes for Clinical Trial, Controlled Clinical Trial, and/or Randomized Clinical Trial under Article Type in the left sidebar.

  • CINAHL Complete This link opens in a new window

    • This link opens in a new window

    Literature in nursing and allied health disciplines, 1937 to present.
    Finding Primary Sources: Under Publication Type, select Clinical Trial and Randomized Clinical Trial. (Hold down the CTRL key to select multiple items in the list)

  • MEDLINE This link opens in a new window

    • This link opens in a new window

    Provides authoritative medical information on medicine, nursing, dentistry, veterinary medicine, the health care system, pre-clinical sciences, and more.
    Finding Primary Sources: Under Publication Type, select Clinical Trial, Controlled Clinical Trial, and Randomized Clinical Trial. (Hold down the CTRL key to select multiple items in the list)

What is a secondary source?

Secondary sources list, summarize, compare, and evaluate primary information and studies so as to draw conclusions on or present current state of knowledge in a discipline or subject. Sources may include a bibliography which may direct you back to the primary research reported in the article.

Secondary Sources include:

  • Reviews, systematic reviews, meta-analysis
  • Newsletters and professional news sources
  • Practice guidelines & standards
  • Clinical care notes
  • Patient education Information
  • Government & legal Information
  • Monographs
  • Entries in nursing or medical encyclopedias

Secondary Sources

  • PubMed This link opens in a new window

    • This link opens in a new window

    Finding Secondary Sources: After conducting your search, select the Systematic Review filter in the left sidebar on the results page.

    What is the nurse's primary source of information when obtaining a patient history?

    Examples of primary sources: Patient interviews. Clinical Trials. Surveys of nursing staff.

    Which primary source of information with the nurse use when completing a patient's assessment?

    The primary source of data collection during the nursing assessment is the patient. Other sources include family, friends, caregivers, and other members of the healthcare team. Data are also collected from laboratory or diagnostic reports, the patient's medical records, and the nurse's observations.

    What information is needed when taking a patient 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 is the primary source of data in nursing?

    A primary source in nursing is one that reports the original findings of a study or experiment. Usually written by the person(s) conducting the research. Types of primary sources include: Case studies.