© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR2 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HealthNOT FOR Assessment SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ©and Jones & Bartlett Diagnostic Learning, LLC Tests© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Beth M. Kelsey © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR2. Presenting SALE problem/illness—chronologicalOR DISTRIBUTION account of problem(s) Health History for which client is seeking care a. Description of principal symptoms should include OLD-CARTS • Purpose and correlation to physical examination mnemonic: (1) Onset 1. Begins the client–clinician relationship © Jones & Bartlett Learning, LLC (2) Location © Jones & Bartlett Learning, LLC 2. Identifies the client’s main concerns NOT FOR SALE OR DISTRIBUTION (3) Duration NOT FOR SALE OR DISTRIBUTION 3. Provides information concerning client’s social determinants of health (4) Characteristics 4. Provides information for risk assessment and health promotion (5) Aggravating/Associated factors 5. Provides focus for physical examination and diagnostic/screening (6) Relieving factors tests © Jones & Bartlett Learning, LLC (7)© T emporalJones factors & Bartlett Learning, LLC 6. Provides information about cultural variations in health beliefs NOT FOR SALE OR DISTRIBUTION (8)NOT Severity FOR SALE OR DISTRIBUTION and practices b. Include pertinent negatives in symptom descriptions; when a • Health history communication principles symptom suggests that an abnormality may exist or develop in 1. Use inclusive language—“partner” or “spouse” instead of “boy- that area, include documentation of the absence of symptoms friend” or “husband”; client-preferred pronouns if transgender, that may help eliminate some of the possibilities © Jones & Bartlettgender nonconforming, Learning, or genderLLC queer; options on forms regard© -Jones &c. BartlettDescribe impact Learning, of illness/problem LLC on client’s usual lifestyle d. Summarize current health status and health promotion/disease NOT FOR SALEing gender OR to DISTRIBUTION include transgender and “other,” with option to writeNOT FOR SALE OR DISTRIBUTION in gender identity prevention needs if client has no presenting problem 2. Assess health literacy—the degree to which an individual is able to 3. Past health history obtain, process, and understand basic health information and ser- a. General state of health as client perceives it vices needed to make health decisions; use appropriate written and b. Childhood illnesses graphic materials, patient© Jones navigators, & trained Bartlett medical Learning, interpreters LLC c. Major adult illnesses © Jones & Bartlett Learning, LLC 3. Use active listening—startNOT with FOR open-ended SALE questions, OR DISTRIBUTION focus on d. Psychiatric illnesses NOT FOR SALE OR DISTRIBUTION what is being said, reflect back on what is heard to confirm mutual e. Accidents/injuries understanding, allow silence for client to have time to express f. Surgeries/other hospitalizations thoughts and feelings g. Blood transfusions—dates and number of units 4. Address sensitive issues in a nonjudgmental, respectful manner; 4. Current health status ensure© Jones confidentiality & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION a. CurrentNOT medications—prescription, FOR SALE OR DISTRIBUTION over-the-counter, herbal, 5. Adopt cultural humility—be humble about recognizing limits of review medications prescribed by all health providers the client own knowledge of a client’s situation, avoid generalizing assump- sees for care (medication reconciliation) tions, be aware of own biases, use patient-centered communication b. Allergies—name of allergen, type of reaction • Components of the health history c. Tobacco, vaping, marijuana, alcohol, substances (e.g., paint © Jones &1. Bartlett Reason for Learning,visit/chief concern—brief LLC statement in client’s own © Jones & Bartlettfumes), prescription Learning, drugs taken LLC as other than intended use, NOT FOR SALEwords ofOR reason DISTRIBUTION for seeking health care NOT FOR SALEillicit drugs—type, OR DISTRIBUTION amount, frequency 7 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 8 CHAPTER 2 Health Assessment and Diagnostic Tests d. Nutrition—24-hour diet recall, recent weight changes, eating b. Parity—total number of pregnancies reaching 20 weeks or © Jones & disorders,Bartlett special Learning, diet LLC © Jonesgreater & Bartlett gestation Learning, LLC NOT FORe. SALEScreening OR tests—dates DISTRIBUTION and results NOT FOR(1) SALEInclude term, OR preterm, DISTRIBUTION and stillbirth deliveries f. Immunizations—dates (2) Include length of each pregnancy; type of delivery; weight g. Sleep patterns and sex of infant; length of labor; complications during h. Exercise/leisure activities prenatal, intrapartum, or postpartum periods; infant complications; cause of stillbirth if known i. Environmental/occupational© Jones hazards & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC c. Ectopic pregnancies—treatment provided j. Use of safety measures—safetyNOT belts,FOR smoke SALE detectors OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION d. Abortions—spontaneous and induced k. Disabilities—functional assessment if indicated e. GTPAL—Gravida, Term, Preterm, Abortion, Living children is 5. Family health history—provides information about possible gen- a commonly used method of obstetric history notation etic, familial, and environmental associations with client’s health f. Any infertility evaluation and treatment a. Age and health or age and cause of death of immediate family members—parents,© Jones & Bartlettsiblings, children, Learning, spouse/significant LLC 8. Menstrual history—may© Jones include& Bartlett in separate Learning, section or in reviewLLC otherNOT FOR SALE OR DISTRIBUTION of systems NOT FOR SALE OR DISTRIBUTION a. Age at menarche, regularity, frequency, duration, and amount b. Specific conditions to ask about—heart disease, hyperten- of bleeding sion, stroke, diabetes, cancer, epilepsy, kidney disease, thyroid disease, asthma, arthritis, blood diseases, tuberculosis, alcohol- b. Date of last normal menstrual period ism, allergies, congenital anomalies, mental illness, genetic c. Use of pads, tampons, douching © Jones & Bartlettdisorders Learning, LLC © Jonesd. Abnormal & Bartlett uterine Learning, bleeding LLC NOT FORc. SALEInclude targetedOR DISTRIBUTION genetic/familial risk assessment for hereditary NOT FORe. Premenstrual SALE ORsymptoms DISTRIBUTION breast and ovarian cancer syndrome as well as other hereditary f. Dysmenorrhea cancer syndromes g. Perimenopausal symptoms d. Indicate if client is adopted and/or does not know family health h. Age at menopause, use of hormone therapy, postmenopausal history © Jones & Bartlett Learning, LLCbleeding © Jones & Bartlett Learning, LLC 6. Psychosocial history 9. Sexual history/contraceptive use—may include in separate section, a. Living situation NOT FOR SALE OR DISTRIBUTIONunder current health status, or inNOT review FOR of systems SALE OR DISTRIBUTION b. Access to care a. Age at first sexual intercourse—consensual/nonconsensual c. Support system b. History of sexual abuse or sexual assault d. Intimate-partner violence/domestic violence c. Sexual orientation e. Stressors© Jones and coping & Bartlett mechanisms Learning, LLC d. Gender ©identity Jones & Bartlett Learning, LLC f. Religious/spiritual/culturalNOT FOR SALE practices OR DISTRIBUTION and preferences e. CurrentNOT sexual relationship(s)FOR SALE OR DISTRIBUTION g. Outlook on present and future (1) Frequency of sexual intercourse h. Special issues to address with adolescent clients include (2) Satisfaction or concerns with sexual relationship(s) HEADSS: Home, Education, Activities, Drugs, Sex, Suicide (3) Dyspareunia, orgasmic or libido problems i. Cultural assessment considerations f. Sexually transmitted infection (STI)/human immunodeficiency © Jones & (1)Bartlett Cultural/ethnic Learning, identification—place LLC of birth, length of © Jonesvirus & Bartlett (HIV) infection Learning, risk assessment LLC NOT FOR SALEtime ORin country DISTRIBUTION NOT FOR(1) SALETotal number OR of DISTRIBUTIONsexual partners and number in past 3 months (2) Communication—language spoken, use of nonverbal com- (2) Types of sexual contact—vaginal, oral, and/or anal munication, use of silence (3) Use of condoms or other barrier methods (3) Space—degree of comfort with distance between self and (4) Previous history of STIs others, degree of comfort with touching by others (5) Use of injection drugs or sex with partner who has used (4) Social organization—family© Jones structure & Bartlett and roles, influence Learning, LLC injection drugs © Jones & Bartlett Learning, LLC of religion/spiritualityNOT FOR SALE OR DISTRIBUTION(6) Sex while under the influenceNOT of FORalcohol and/orSALE drugs OR DISTRIBUTION (5) Time—past-, present-, or future-oriented; view of time— (7) Previous testing for HIV clock-oriented or social-oriented g. Current and future desire for pregnancy (6) Environmental control—internal or external locus of h. Contraceptive use © control, Jones belief & in Bartlett supernatural Learning, forces LLC (1) Establish© Jones if pregnancy & Bartlett is not a concern—hysterectomy, Learning, LLC (7) Use of culturally based healing practices or