• Obtained in the first visit.

• Goals:

  • Gather complete and accurate data about the person's health state, including the description and chronology of any symptoms.

  • Establish trust so that the person feels accepted and thus free to share all relevant data.

  • Teach the person about their health state.

  • Build rapport for a continuing therapeutic relationship.

  • Discuss health promotion and disease prevention.

1. Greeting

2. Provide privacy

3. Wash hands

4. Verify Name & DOB

• name, address, and phone number; age and birth date; birthplace; gender and preferred pronoun; relationship status; race; ethnic origin; primary language; and occupation.

• Can be obtained from the chart.

• Observe:

consc

Color

build,

• Leads to diagnosis and treatment

• Not a diagnostic statement

• Identify:

  • Location

  • Characteristics

  • Quantity or Quality/Severity

  • Timing: Onset, Duration, Frequency

  • Setting

  • Aggravating or Relieving Factors

  • Associated Factors

  • Patient's Perception: "How has this affected you?" "What do you think might be causing you to feel this way?"

• You may find it helpful to organize this question sequence into the mnemonic PQRSTU to help remember all the points.

• Medical

  • Past medications

  • [Allergies]: Medication, Seasonal/Environmental, Food, Specific allergens- latex.

    • Follow-up Questions

      • How they react

      • How they treat

      • How they prevent

  • [Substance use]: Alcohol, Tobacco, Nicotine, Illicit Drugs

    • Follow-up Questions

      • When use began

      • How often

      • How they feel about use

  • Past blood transfusions and any reactions

  • Recent screenings/tests

  • Chronic medical conditions

  • Past diagnoses (childhood and adult)

  • Immunizations

  • Past surgical procedures

  • Serious injuries or functional limitations

  • Obstetric History

• Prescriptions

• Over-the-counter

• Supplements like vitamins or herbals

Follow-up Questions:

• Reason

• Doseage

• Quantity at once

• Frequency

• Illnesses similar to the patient's illness

• History of major diseases

  • Heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, allergies, breast/ovarian cancer, colon cancer, sickle cell anemia, arthritis, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis (TB)

• Familial disease and cancer history (genetic illnesses; chronic diseases, such as diabetes, and heart disease; types of cancer)

• Note age at onset of illness and outcome

• Ethnic and racial background of the family

• Create a pedigree (genogram) diagram (notes disorders of past three generations in a family tree diagram)

• Evaluate each system head to toe. Double check that no details are missing. Evaluate health promotion practices.

• Subjective data section

• Present weight (gain or loss, over what period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats.

• History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion. Recent hair loss or change in texture. Change in shape, color, or brittleness of nails.

• Health Promotion: Amount of sun exposure, use of sunscreen; method of self-care for skin and hair.

• Any unusually frequent or severe headache; any head injury, dizziness (syncope), or vertigo. Any history of concussion (with or without loss of consciousness).

• Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts. Eye surgery, reason, outcome.

• Health Promotion: Wear glasses or contacts; last vision check and glaucoma test; how coping with loss of vision if any.

• Earaches, infections, discharge and its characteristics, tinnitus or vertigo.

• Health Promotion: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, and method of cleaning ears.

• Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, snoring, nosebleeds, allergies or hay fever, or change in sense of smell.

• Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste.

• Health Promotion: Pattern of daily dental care, use of dentures, bridge, and last dental checkup.

• Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter. Recent injuries.

• Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts.

• Health Promotion: Performs breast self-examination? How frequently? Method used? Last mammogram?

• Tenderness, lump or swelling, rash.

• History of lung diseases (asthma, emphysema, bronchitis, pneumonia, TB), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.

• Chest pain, pressure, tightness or fullness, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion [e.g., walking one flight of stairs, walking from chair to bath, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary heart disease, anemia.

• Vigorously pursue all vague chest pain similarities. A variety of symptoms may indicate heart disease, and each patient presents differently.

• Health Promotion: Date of last ECG or other cardiac tests, cholesterol screening.

• Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers.

• Health Promotion: Does the work involve long-term sitting or standing? Does the patient frequently cross legs at the knees? Wear support hose?

• Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (liver or gallbladder, ulcer, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions (hemorrhoids, fistula).

• Health Promotion: Use of antacids or laxatives. (Alternatively, diet history and substance habits can be placed here.)

• Frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change); dysuria; polyuria or oliguria; hesitancy or straining, narrowed stream; urine color (cloudy or presence of hematuria); incontinence; history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back.

• Health Promotion: Measures to avoid or treat urinary tract infections, use of Kegel exercises after childbirth.

• Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.

• Health Promotion: Perform testicular self-examination? How frequently?

• Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.

• Health Promotion: Last gynecologic checkup and last Pap test; HPV vaccine.

• Begin with: "I ask all patients about their sexual health." Then ask: "Are you presently in a relationship involving sexual activity? Are the aspects of sex satisfactory to you and your partner? Are condoms used routinely (if applicable)? Is there any dyspareunia (for female) or are there any changes in erection or ejaculation (for male)? Are contraceptives used (if applicable)? Is the contraceptive method satisfactory (if applicable)? Are you aware of contact with a partner who has any sexually transmitted infection (chlamydia, gonorrhea, herpes, venereal warts, HIV/acquired immunodeficiency syndrome [AIDS], or syphilis)?"

• Health Promotion: Routine testing for sexually transmitted infections and use of preexposure prophylaxis if applicable.

• History of arthritis or gout. In the joints: Pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion? In the muscles: Any muscle pain, cramps, weakness, gait problems, or problems with coordinated activities? In the back: Any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disc disease? Any recent injuries to the joints, muscles, or back?

• Health Promotion: How much walking per day? Any strength training (e.g., weight training, resistance training)? What is the effect of limited range of motion on ADLs such as grooming, feeding, toileting, dressing? Are any mobility aids used?

• History of seizure disorder, stroke, fainting, blackouts. Motor function: Weakness, tic or tremor, paralysis, or coordination problems? Sensory function: Numbness, tingling (paresthesia)? Cognitive function: Memory disorder (recent or distant, disorientation)? Mental status: Any nervousness, mood change, depression, or history of mental health dysfunction or hallucinations? Conduct suicide screening on all patients.

• Health Promotion: Alternatively, data about interpersonal relationships and coping patterns are placed here.

• Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.

• History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormone therapy.

• Education, financial status, value belief system (religious, spiritual, or cultural beliefs)

  • May give insight on support systems

• A daily profile reflecting usual daily activities. Ask, "Tell me how you spend a typical day." Note ability to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs. Is there any use of a wheelchair, prostheses, or mobility aids?

• Record leisure activities enjoyed and the exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the response of the body to exercise).

• Sleep patterns, daytime naps, any sleep aids used. Screen for sleep apnea as appropriate.

• Record the diet by a recall of all food and beverages taken over the past 24 hours. Ask, "Is that menu typical of most days?"

• Describe eating habits and current appetite. Ask, "Who buys food and prepares food? Are your finances adequate for food? Who is present at mealtimes?"

• Indicate any food allergy or intolerance. Record daily intake of caffeine (coffee, tea, cola drinks).

• Ask about usual pattern of bowel elimination and urinating, including problems with toileting, any incontinence, use of laxatives.

• Social roles: Ask, "How would you describe your role in the family? How would you say you get along with family, friends, and co-workers?" Ask about support systems composed of family, friends, and significant others: "To whom could you go for support with a problem at work, with your health, or a personal problem?" Include contact with partner, siblings, parents, caregivers, children, friends, organizations, workplace. "Is time spent alone pleasurable and relaxing, or is it isolating?"

• Presence of a spouse, close friend, or another person who can be contacted in the case of an emergency

• Could identify if a victim of abuse

• Many people believe in a relationship between spirituality and health, and they may wish to have spiritual matters addressed in the traditional health care setting. Use a standard approach such as the Faith, Influence, Community, and Address (FICA) questions to incorporate the person's spiritual values into the health history.

  • Faith: "Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?"

  • Influence: "How does your religious faith or spirituality influence the way you think about your health or care for yourself?"

  • Community: "Are you a part of any religious or spiritual community or congregation?"

  • Address: "Would you like me to address any religious or spiritual issues or concerns with you?"

• Types of stresses in life, especially in the past year; any change in lifestyle or any current stress; methods tried to relieve stress and whether these have been helpful.

• Self Care: physical and emotional health

• Ask, "Do you smoke cigarettes (pipe, use chewing tobacco)? At what age did you start? How many packs do you smoke per day? How many years have you smoked?" Record the number of packs smoked per day (PPD) and duration (e.g., 1 PPD × 5 years).

• Then ask, "Have you ever tried to quit?" and "How did it go?" to introduce plans about smoking cessation.

• Health care professionals often fail to question about alcohol unless problems are obvious. However, alcohol interacts adversely with all medications; is a factor in many social problems such as assaults, rapes, high-risk sexual behavior, and child abuse; contributes to half of all fatal traffic accidents; and accounts for 5% of all deaths in the United States.

• Ask whether the person drinks alcohol. If yes, ask specific questions about the amount and frequency of alcohol use: Ask, "When was your last drink of alcohol? How much did you drink that time? In the past 30 days, about how many days would you say that you drank alcohol? Has anyone ever said that you had a drinking problem?"

• Ask about marijuana use for medicinal and recreational purposes. If the person reports using marijuana for medicinal purposes, ask about the condition and symptom(s) the marijuana treats. Were other therapies used prior to marijuana? For any marijuana use, inquire about frequency, type of delivery (e.g., oral, smoked), and source (e.g., dispensary). If the patient reports marijuana use, provide counseling on safety. Marijuana use is associated with poor mental health outcomes, motor vehicle accidents, and cognitive decline, especially in adolescents and young adults.

• Ask specifically about prescription painkillers such as OxyContin or Norco, cocaine, crack cocaine, amphetamines, and heroin. Indicate frequency of use and how use has affected work or family.

• Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Ask minority clients about racism and discrimination as you assess safety and environmental hazards. Note environmental health, including hazards in the workplace, hazards at home, use of seatbelts, geographic or occupational exposures, and travel or residence in other countries, including time spent abroad during military service.

• Begin with open-ended questions: "How are things at home?" and "Do you feel safe?" These are valuable initial screening questions because some people may not recognize that they are in abusive situations or may be reluctant to admit it because of guilt, fear, shame, or denial. If the person responds to feeling unsafe, follow up with closed-ended questions: "Have you ever been emotionally or physically abused by your partner or someone important to you? Within the past year, have you been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?" If yes, ask: "By whom? How many times?" Ask: "Does your partner ever force you into having sex? Are you afraid of your partner or ex-partner?"

• Ask the person to describe their job. Ever worked with any health hazard such as asbestos, inhalants, chemicals, repetitive motion? Wear any protective equipment? Any work programs in place that monitor exposure? Aware of any health problems now that may be related to work exposure?

• Note the timing of the reason for seeking care and whether it may be related to change in work or home activities, job titles, or exposure history. Take note of whether the visit is due to a workplace injury. Take a careful smoking history, which may contribute to occupational hazards. Finally, ask the person what they like or dislike about the job.

• may also give information about the patient's financial status and potential problems accessing care

Interview Techniques

• Set clear expectations about the visit

  • Time and place

  • Duration

  • Purpose

  • Confidentiality and its limitations

  • Costs for care

  • Introduce yourself and address pt appropriately

    • Courteous, culturally appropriate eye contact, personal space

• Don't exhaust patient

• Ask in non-judgemental way

• Be empathetic

• Be flexible

• Be aware of your/pt verbal and non-verbal communication

  • Confirm that your message is being received as intended as messages can be interpreted in a variety of ways.

  • Pay attention to pt/your

    • Physical appearance

    • Posture

    • Gestures

    • Facial expressions

    • Eye contact

    • Voice and Tone

    • Touch

  • Maintain your internal factors as to not convey negative vibes

    • Liking Others: Accept patients unconditionally and create a warm and caring environment.

    • Empathy: accept patients feelings without criticism

    • Active Listening: interpreting their meaning, asking follow-up questions, and ensuring a thorough understanding

    • Self Awareness: Be aware of your personal biases, prejudices, and any stereotypes. Ask a colleague to assist if not possible.

• Ensure privacy

• Refuse interruptions

• Create a comfortable, quiet environment free from distractions

• Sit about 4-5 feet away from the patient, ideally, place seating at 90degrees. Do not stand above the patient as it creates superiority.

• Conduct most of the interview and establish rapport before asking the person to change into a gown.

• Keep note-taking to a minimal without missing details

• Allow the pt to discuss their main concern early and maintain active listening to build rapport.

• Do not answer inappropriate questions asked by the pt and try to redirect the conversation back to the pt's health.

• Be aware of low health literacy. There are some tools available to assist in assessing literacy.

  • Educate the pt about their health

  • Provide written materials

  • Have the pt summarize what they learned

1. Providing false reassurance

2. Giving unwanted advice

3. Using authority

4. Using avoidance language (passed on instead of died)

5. Distancing: use pronouns when addressing pt body parts

6. Using professional jargon

7. Using leading questions (you dont _____, do you?"

8. Talking too much

9. Interrupting

10. Using "Why?" questions: implies blame

• Include the caregiver in the interview.

• Ask about prenatal status, delivery, and postnatal status.

• Discuss growth and milestones for all ages.

• Explore sensitive topics alone with the caregiver.

• Involve the child in the conversation as deemed appropriate.

• The younger the child, the more detailed and specific the nutritional data should be.

• Infants read nonverbal cues and ensure their needs are met. If child is developmentally exhibiting stranger anxiety, allow the parent to be close or to hold them.

• At 1-3 years, provide simple explanations when desired, use simple directions, provide simple choices and warnings about transitions when possible.

• Between 1-6 years, ignore the child at first and allow them to observe your interaction with their guardian to establish trust.

• At 3-6 years, avoid metaphors, educate about the visit and tools used as needed.

• At 7-12 years, address the child first about the chief concern before seeking additional information from the caregiver.

• Adolescents believe that you don't understand them. Establish trust by establishing respect for them, always telling the truth, maintaining your role as a healthcare provider, and allow the pt to talk about themselves before addressing their chief concerns.

  • Provide direction and reasoning about the visit.

  • Encourage questions.

  • Avoid silence that is not brief as it is interpreted as threatening.

  • Provide privacy. Ask the caregiver to leave when asking about sensitive topics.

  • Ensure that you are concerned about their health and are not trying to be intrusive.

  • Use positive reinforcement whenever possible.

  • Discuss:

    • Home environment

    • Education and employment

    • Eating

    • Activities related to peers

    • Drugs

    • Sexuality

    • Suicide/depression

    • Safety (including driving)

• Address by surname.

• Avoid diminutives (honey, sweetie, dearie).

• Avoid improper plural pronouns (Are we ready for the interview?)

• Avoid shortened sentences

• Avoid slow speech rate

• Avoid simple vocabulary

• Avoid changing pitch and tone of voice

• Plan for a longer interview time and don't rush the pt

• Consider hearing impairments and wheelchairs

• Touch is an important nonverbal skill- a hand on the arm can communicate an empathetic message that you want to understand.

• Hearing Impairment

  • Ask the preferred method of communication---signing, lipreading, or writing.

  • Ensure hearing aides are functioning properly

  • Visual aids and hand gestures are helpful

• Acutely Ill

  • Be direct and consice

  • Address pain beforehand if possible

  • In emergent situations, inquire about the most pertinent information

• Under the Influence of Drugs or Alcohol

  • Ask simple and direct questions

  • Avoid confrontation

  • The top priority is to find out the timing of alcohol or drug use, how much was consumed or taken, and the name of each substance.

• Sexually Aggressive

  • Communicate the importance of a professional relationship in addressing health concerns.

  • Communicate that you will not tolerate sexual advances.

  • Remain non-judgmental

  • Set clear verbal boundaries

  • Seek a colleague if pt persists

• Crying

  • Crying is relieving.

  • Do not avoid topics that cause crying.

  • Silence and touch are useful techniques when a client is crying.

  • Do not interrupt and do not use false reassurance.

  • You can reassure the client that crying is normal and they do not need to feel embarrassed.

  • Let the person know that you are there to listen.

  • Confront sad appearance

• Anger

  • Address anger first

  • Do not take it personally

• Threats of Violence

  • Identify red-flags

    • fist clenching, pacing, a vacant stare, confusion, statements out of touch with reality or that do not make sense, a history of recent drug use, or a recent history of intense bereavement

  • If you sense any suspicious or threatening behavior, act immediately to defuse the situation, or obtain additional support from others.

  • Keep the door open and place yourself between the pt and the door.

  • Be aware of the facility's policies regarding violent clients.

  • Appear unhurried.

• Anxiety

  • Appear unhurried.

  • Avoid interview traps.

  • Use therapeutic responses.

• Cultural Considerations of Gender

  • Violating cultural or religious norms related to appropriate male-female relationships may jeopardize a professional relationship.

  • Be aware of personal bias

  • As you ask questions, engage with your patient through listening to their responses about their background, identity, values, as well as their health beliefs and practices.

  • As you learn more about your patient, convey respect

  • Be attentive to avoid expressing nonverbal cues that could communicate negative judgment

• Sexual Orientation and Gender Identity

  • Avoid heterosexist assumptions.

  • Avoid other assumptions.

  • Update registration and admitting forms using inclusive language.

  • Ask pt preferred pronoun.

  • Be non-judgmental

  • Be aware of bias and language

  • Be aware of health disparities

• Complete total health database

  • Describes current and past health state and forms a baseline to measure all future changes.

  • Yields First diagnosis

  • Complete Health History

  • Full Physical Examination

• Focused or problem-centered database

  • Collect "mini" database, smaller scope and more focused than complete database.

• Follow-up database

  • Status of all identified problems should be evaluated at regular and appropriate intervals.

• Emergency database

  • Rapid collection of data often compiled concurrently with lifesaving measures

Subjective Data: When a patient verbally reports information.

Objective Data: Data gathered by practitioner

• What

• How

• Tell me about

• Describe

• When

• For how long

• How many

• How often

• Rate

• Do you

• Have you (ever)

• Are you

• Begin at admission

• Consider limitations to learning

• Understand their POV

• Find out what the patient already knows

• Determine learning style

• Understand the material

• Choose right time to educate

• Do not use medical jargon

• Use visual aids

• Stimulate their interests

• Ensure they understand the medication

• Provide information for the patient to understand signs and symptoms that would require them to seek care

• Involve companions in teaching when possible

• Patients understanding or responding to questions, and anxious patients may have a lack of focus during the interview.

• The nurse must take steps to overcome these barriers to obtain a complete, accurate patient history.

• Establish a clear communication system, make sure the patient is comfortable, and modify the assessment based on the patient's needs and abilities.