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History Taking

Health Assessment

S.O.A.P. Subjective Data, Objective Data, Assessment, Plan
Subjective Data: Health history obtained through questions and explanations. Information the patients relays to the healthcare provider!
Objective Data: Examination of body systems and expected findings. What the healthcare provider sees!
Assessment: Diagnosis.
Plan: plan care
Biographical Data: Name, address, phone number, age, DOB, birthplace, gender, marital status, race, ethnic origin, and occupation.
Source of history. Who furnishes the information? Judge how reliable the informant seems and how willing he or she is to communicate. Note any special circumstances such as use of an interpreter.
Reason for Care: Brief spontaneous statement in the person’s own words that describes the reason for the visit.
Present Health or History of Present Illness: For the well person, this is a short statement of the general state of health.
Present Health or History of Present Illness: For the ill person, this is a chronological record of reason for seeking care.
Present Health or History of Present Illness - Include these eight critical characteristics: Include these eight critical characteristics: Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, Patients Perception
You may also organize the same characteristics into the mnemonic: PQRSTU
P: Provocative or Palliative
Q: Quality or Quantity
R: Region or Radiation
S: Severity Scale
T: Timing
U: Understand Patient’s Perception
Past Health: Childhood Illnesses, Accidents or Injuries, Serious or Chronic Illness, Hospitalizations, Operations, Obstetric History, Immunizations, Last Examination Date, Allergies, Current Medications
Family History: (family tree or genogram) Parents, Grandparents, Siblings, Children
Review of Systems: (head to toe) - subjective data: what the patient tells you To evaluate the past and present health state of each body system. To obtain significant data that may have not been discussed in the present illness section. To evaluate health promotion practices.
Functional Assessment: Self-Esteem/Self-Concept, Activity/Exercise Sleep/Rest, Nutrition/Elimination, Interpersonal Relationships/Resources, Spiritual Resources, Coping and Stress Management
Functional Assessment: continued Personal Habits: (Tobacco, ETOH, Street Drugs), Environmental/Hazards, Intimate Partner Violence, Occupational Health
Children and Adolescents: Information specific for the age and developmental stages of the child. Mother’s health during pregnancy, labor, delivery and perinatal important. Developmental History & Nutrition.
Pediatric Health History: Chief complaint, Maternal/Paternal concerns, Interval history, History of present illness, Past medical history, Prenatal history, Family history, Social history
General Health and Growth for Pedi: Get an assessment of what the parents’ evaluation is of the child’s growth and development. Any weight loss or gain, how much and over what time interval? Any recent illness…etc?
The Older Adult - Geriatric Patient: Reason for seeking care, Past health - general health state in the last 5 years, Thorough functional assessment, Accidents or injuries, serious or Chronic illnesses, hospitalizations, operations Last examination, Obstetric status, Current medications
Created by: mr209368