SHADOW HEALTH: HEALTH HISTORY - WEEK 2 - TINA JONES
Study online at https://quizlet.com/_ee1r6d
1. HEALTH HISTORY - ACTIVITY DESCRIPTION VIDEO
TINA JONES
2. The purpose of obtaining a health history is to gather subjective data from
the patient and/or their care partners to collaboratively create a nursing care
plan that will promote health and maximize functioning.
3. GREETING Hi Ms. Jones. My name is [your name] and i will be your nurse for today.
4. HPI (History of Pre- What brings you to the hospital today?
sent Illness) (Allow the patient to answer)
START W/ OPEN-END-
ED QUESTIONS
5. EMPATHIZE - MAKE I'm sorry your're in so much pain. I'm glad you're here so we can help you.
AN EMPATHETIC
STATEMENT
(Helps to build rap-
port and trust with
the patient.)
6. QUALIFY SYMPTOMS - Use O-L-D C-A-R-T-S acronym as a reminder of what to ask.
GET MORE INFORMA- O - Onset
TION ON CONDITION l - Location
(I.E., INJURY) D - Duration
C - Characteristics
A - Aggravating Factors
R - Relieving Factors
, SHADOW HEALTH: HEALTH HISTORY - WEEK 2 - TINA JONES
Study online at https://quizlet.com/_ee1r6d
T - Treatment
S - Severity
7. PAIN LEVEL Can you rate your pain on a scale of 1 to 10?
8. ONSET When did the pain start?
9. BRIEFLY EMPATHIZE I'm sorry you're in so much pain. I will get you pain medication as soon as
AGAIN possible.
10. LOCATION Where is your wound?
11. CONVERSATION HELP Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she, they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g. "last pap?")
, SHADOW HEALTH: HEALTH HISTORY - WEEK 2 - TINA JONES
Study online at https://quizlet.com/_ee1r6d
Ask about one subject at a time.
Use the Educate and Empathize tabs.
If you don't get an answer, try asking a more broad question.
12. PAST MEDICAL HISTO- Preexisting medical condition
RY Prior hospitalizations
Medications
Allergies
Immunizations
13. PREEXISTING MED- Do you have any other medical conditions?
ICAL CONDITIONS
14. MORE INFO ON When were you diagnosed with diabetes?
PRE-EXISTING CONDI- How are you managing your diabetes?
TION(S) Do you take any diabetes medication?
Why did you stop taking your diabetes medication?
Are you monitoring your blood glucose?
15. EDUCATE - DIABETES Educate on the proper management of diabetes.
MANAGEMENT
Diabetes medication helps your body release or use insulin better, which
keeps your body from making too much sugar. It also helps prevent or delay
long-term, serious health problems, such as heart disease, vision loss, and
Study online at https://quizlet.com/_ee1r6d
1. HEALTH HISTORY - ACTIVITY DESCRIPTION VIDEO
TINA JONES
2. The purpose of obtaining a health history is to gather subjective data from
the patient and/or their care partners to collaboratively create a nursing care
plan that will promote health and maximize functioning.
3. GREETING Hi Ms. Jones. My name is [your name] and i will be your nurse for today.
4. HPI (History of Pre- What brings you to the hospital today?
sent Illness) (Allow the patient to answer)
START W/ OPEN-END-
ED QUESTIONS
5. EMPATHIZE - MAKE I'm sorry your're in so much pain. I'm glad you're here so we can help you.
AN EMPATHETIC
STATEMENT
(Helps to build rap-
port and trust with
the patient.)
6. QUALIFY SYMPTOMS - Use O-L-D C-A-R-T-S acronym as a reminder of what to ask.
GET MORE INFORMA- O - Onset
TION ON CONDITION l - Location
(I.E., INJURY) D - Duration
C - Characteristics
A - Aggravating Factors
R - Relieving Factors
, SHADOW HEALTH: HEALTH HISTORY - WEEK 2 - TINA JONES
Study online at https://quizlet.com/_ee1r6d
T - Treatment
S - Severity
7. PAIN LEVEL Can you rate your pain on a scale of 1 to 10?
8. ONSET When did the pain start?
9. BRIEFLY EMPATHIZE I'm sorry you're in so much pain. I will get you pain medication as soon as
AGAIN possible.
10. LOCATION Where is your wound?
11. CONVERSATION HELP Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she, they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g. "last pap?")
, SHADOW HEALTH: HEALTH HISTORY - WEEK 2 - TINA JONES
Study online at https://quizlet.com/_ee1r6d
Ask about one subject at a time.
Use the Educate and Empathize tabs.
If you don't get an answer, try asking a more broad question.
12. PAST MEDICAL HISTO- Preexisting medical condition
RY Prior hospitalizations
Medications
Allergies
Immunizations
13. PREEXISTING MED- Do you have any other medical conditions?
ICAL CONDITIONS
14. MORE INFO ON When were you diagnosed with diabetes?
PRE-EXISTING CONDI- How are you managing your diabetes?
TION(S) Do you take any diabetes medication?
Why did you stop taking your diabetes medication?
Are you monitoring your blood glucose?
15. EDUCATE - DIABETES Educate on the proper management of diabetes.
MANAGEMENT
Diabetes medication helps your body release or use insulin better, which
keeps your body from making too much sugar. It also helps prevent or delay
long-term, serious health problems, such as heart disease, vision loss, and
