Health history: Nursing

Collecting a client’s health history provides the nurse with information about their perceived health and factors that can impact their health. It should be completed as part of a comprehensive client assessment, like upon admission to the hospital, during a medical office visit, or as part of a focused exam. Typically, the health history includes subjective data, or information the client is experiencing, such as when a client states, “I become nauseous after most meals.” This can guide the nurse to focus the physical assessment on the gastrointestinal system, as well as client education and the plan of care. Although the client is the preferred source of subjective data, if they’re unable to communicate a secondary data source can be used, such as a family member or caretaker. In addition, if the client doesn’t speak the same language as the nurse, an institutionally-approved medical interpreter should be used. Okay, let’s review how to conduct a health history.

Now, you’ll want to collect your client’s health history in a private, quiet, and comfortable setting free from environmental distractions or interruptions. Also remember that as the nurse, you are responsible for collecting and documenting your client’s health history. And since it involves assessment and nursing judgment, the health history shouldn’t be delegated to another member of the healthcare team, like unlicensed assistive personnel. Begin by establishing rapport with your client. You can do this by introducing yourself, including your name and role, and asking them how they would like to be addressed or if they have a preferred nickname. If there is someone accompanying your client, ask their name and relationship to your client. As you collect data, remember to look at them, and avoid focusing your attention on the electronic health record, or EHR. This will help avoid the impression that you’re not listening to them or that you are rushed. With each question, allow them the time they need to answer fully, and avoid interrupting them. If you’re unsure what they mean, take time to seek clarification.

You can be mindful of your own professional time constraints, as well; so if they stray from the topic, redirect them or ask questions such as, “Of everything you’ve described, which is your most pressing concern?” Now, keep in mind, there are sensitive issues which may be difficult for your client to discuss, such as sexuality, drug or alcohol consumption, palliative care, or death. So, be sure you have provided adequate privacy; remember to be direct and compassionate; and be mindful of your own nonverbal cues, such as facial expressions and body language like crossing your arms. Also, use language that’s understandable to your client rather than technical terms or medical jargon. Lastly, like all components of an assessment, accurate documentation is essential, so take thorough notes and use their exact words in quotation marks when appropriate. So, there are several components of a health history, including client identifiers, chief concern, history of present illness, past medical history, family history, personal and social history, and the review of systems.