Learning Objectives
By the end of this section, you will be able to:
- Discuss how to obtain a comprehensive health history
- Discuss the different parts of the comprehensive health history
The health history of a patient provides direction for their care and helps clarify the patient’s needs. There are two main nursing assessments: a focused health history and a comprehensive health history. A focused health history is tailored to the reason the patient’s chief complaint, or the reason the patient is currently seeking care. The patient’s health history, in this case, relates to exploring the chief complaint. When performing a comprehensive health history, the nurse must address the patient’s problem in depth. At this level, the nurse will ask about the present illness but also about past medical history, allergies, social factors, lifestyle habits, and health risks, including family history. This assessment is a more thorough examination of the patient’s overall health history and captures the various factors that affect a patient’s health.
Obtaining a Comprehensive Health History
The most common way to obtain a health history is by interviewing the patient. As a nurse, there are some best practices to keep in mind when gathering this crucial health information. Make sure that the room is conducive to clear, effective communication. The space should be private, comfortable, and as free from distraction as possible. The nurse should then “prime” the conversation by building rapport and trust. Being an empathetic, active listener, ensuring communication needs are met, being self-aware, and keeping cultural and age-related factors in mind are all key to getting the information the nurse needs from the patient.
Following regulatory and institutional policies, procedures, and protocols for data gathering and recording may make this process more efficient, accurate, and streamlined. Following structured formats and using technology are among the key practical aspects of obtaining a health history. This may include using questionnaires to assess specific patient problems and knowing how to navigate and document in the patient’s electronic health record (EHR). Throughout the process of data-gathering, nurses must observe how the patient is responding and adjust to facilitate effective communication. The nurse needs to continually monitor their own behavior and recognize when their body language may be communicating a message to the patient that they do not intend. One common mistake nurses may make is staring too long at a computer screen while documenting, leaving the patient feeling isolated and ignored in the exam room. Try to maintain focus, both visually and verbally, on the patient. When the nurse has to attend to the computer, they should explain to the patient that reviewing and documenting relevant information helps with clinical decision-making. This way, the patient should not feel ignored. A nurse’s position in the room can make a patient feel more open or closed off throughout the dialogue. For example, a nurse who is standing completely behind the rolling computer cart versus being seated, facing the patient, and “on their level” may be perceived to be less engaged, concerned, or empathetic (Lanier et al., 2021; Misto et al., 2019).
There will be times when the nurse needs to do a bit of problem-solving when obtaining the patient’s history to establish clarity. If the patient is unable to provide a history, then the family can be interviewed to obtain the information. If the patient has brought many health documents with them, such as a list of medications or health conditions, notes on their surgical history, and/or advanced directives, this information may help the nurse piece together a complete history, along with what can be gathered from the patient’s social and family history through interviewing. By assembling the components, the nurse gives the provider and care team a strong starting point to pursue the diagnostic puzzle and create a patient-centered, evidence-based treatment plan.
From the overall perspective of clinical practice, a focused (as opposed to comprehensive) assessment helps address the shortage of time that burdens the health care system at every level. Being efficient but thorough in gathering data respects the nurse’s and patient’s time (Figure 6.4). While the nurse must understand that each patient has a multifaceted and complex life, it is often necessary to focus the health history on the patient’s current health. To ensure that the nurse is able to gather relevant data efficiently and accurately, they will need to guide the patient through the interview and maintain the focus on why they are seeking care from the provider at the present time.
For example, a common chief complaint is pain. To help the provider solve the problem, the nurse will talk to the patient and recognize cues about the cause or source of the pain, as well as analyze and hypothesize how the pain could be treated or managed. The history, in this example, is not always one that is “far back” in the patient’s life. Instead, it might be just a few days or weeks ago, depending on when the pain began.
Asking specific, open-ended questions like “How long have you had the pain?” gives the patient a chance to elaborate on what they’re experiencing and supply the nurse with data. Asking more questions, such as whether there is anything that makes the pain better or worse, and inquiring about associated symptoms (e.g., nausea), creates a more complete picture of the patient’s problem.
Elements of the Comprehensive Health History
The elements of the health history help the nurse gather data to support the patient’s current health concern. The format has several general components (UCF College of Medicine, 2018; Nichol et al., 2024):
- Chief complaint: Patient’s specific, current problem (e.g., cough, sore throat)
- History of present illness: Details about chief complaint (e.g., duration and intensity)
- Past medical history: Chronic illnesses, mental health conditions
- Surgical history: Any procedures or surgeries
- Medications: Current prescriptions, over-the-counter (OTC) supplements, herbal remedies, or vitamins
- Allergies: Environmental, drug; details of symptoms, reactions
- Family history: Medical conditions, genetic disorders, risk factors
- Social history: Lifestyle habits, diet, physical activity, sexual health, living situation
- Review of systems (ROS): Allows the nurse to obtain specific, objective data on a patient’s health by assessing each body system, one by one
- Social determinants of health: Sociocultural factors that may influence a patient’s health
The ROS, physical exam, diagnostic tests, problem list, summary, and plan/assessment are information-gathering components that come later.
Chief Complaint and History of Present Illness
A health history starts with the patient’s chief complaint, which is the reason they are presently seeking care. Asking about the history of present illness is how the nurse gathers additional context about the chief complaint to help the care team form a diagnosis and treatment plan.
Here’s a common example: A 32-year-old patient comes to their primary care provider’s (PCP’s) office with a chief complaint of a sore throat. The nurse needs to get more details from the patient about the symptom to gather the information the provider will need to determine the cause of the patient’s symptom. What possible explanations might the provider want to consider, and how can the health care team get the information necessary to solve the diagnostic puzzle? Is the patient experiencing a sore throat because they have strained or overused their voice? Do they have a viral illness? Is it related to a chronic condition?
The nurse needs to ask the patient questions like, “When did the sore throat start?” to establish a timeline of the problem. If the patient states that the pain began two days ago, the nurse can find what the patient was doing around that time that could have contributed to the pain. For example, if the patient visited a theme park the day before and rode roller coasters, screaming in excitement as they did, it’s possible that the pain is from overuse or strain. But the nurse still needs to gather more information rather than making assumptions.
A patient who visited an amusement park would also have been spending time around others and could have been exposed to a virus. It’s important to ask the patient whether they have any other signs or symptoms, like a fever or congestion, that could support the thought that their sore throat is from an illness. Asking about other signs and symptoms also provides information that helps differentiate between an infectious and noninfectious cause. A patient with a sore throat and congestion but no fever may have seasonal allergies, which could also be noted in their medical history. A patient with a fever and a sore throat may have a viral or bacterial infection, particularly if they report being around a sick person recently.
Clinical Judgment Measurement Model
Recognize and Analyze Cues
Before a nurse can analyze cues to form a hypothesis, they must first make sure they have enough information about a patient’s situation to correctly interpret the information and develop a plan of care. Suppose a patient claims to have an allergic reaction to all vaccines. The nurse will need to assess further. For example, the nurse will need to ask what symptoms the patient experienced to determine if the patient’s reaction was truly an allergen-induced response or a side effect of the vaccination. The patient may report an allergy to the flu vaccine by stating they experienced redness at the injection site after taking the flu shot last year. However, redness at the injection site is a common side effect of all vaccinations; it is not necessarily a sign of an allergy. Only after considering all relevant information should the nurse move on to the next step of the Clinical Judgment Measurement Model: prioritizing a hypothesis and providing the appropriate education to the patient.
(NCSBN, n.d.)
Past Health History
A patient’s past health history includes any childhood illnesses, immunization record, current conditions, acute illnesses, accidents, injuries, and chronic illnesses, as well as any treatments. Even though these may not all be obviously relevant to the patient’s chief complaint, they can provide the nurse with key insights.
Take the patient with a sore throat as an example. A patient with a fever and sore throat that began two days after a trip to an amusement park could have a common viral or bacterial infection like strep throat, the flu, a cold, or COVID-19. If the patient’s past health history shows they were diagnosed with lupus several years ago, the nurse might consider that the excursion and ensuing exhaustion could have triggered a flare. What additional information does the provider need? Does the patient have a rash? Have they been taking their medications as prescribed?
Family History
When interviewing the patient, inquire about chronic conditions or diseases in the patient’s immediate family, including parents and siblings, and ask about the health of their immediate family members, which primarily includes their parents and siblings. Do any of them have any chronic conditions? Are there any diseases or health risks that the patient may have a genetic predisposition to? While it may not seem immediately applicable to the patient’s current problem, the information the nurse gathers here helps create a more complete picture of the patient’s health.
Review of Systems
The ROS covers more of the physical health details of the patient’s chief complaint. Each body system can offer clues about the patient’s current problem, though the nurse will want to pay particular attention to those that are most relevant to the patient’s present symptoms. For the patient with a fever and sore throat, the upper body systems—including the head, face, neck, and respiratory systems—may hold pertinent clues about the cause of the patient’s throat pain. Whole-body, or constitutional, signs and symptoms, such as fever and fatigue, can also provide insight into the cause of the patient’s pain.
The body systems covered in the problem pertinent ROS include (Vanderbilt University Medical Center, 2019):
- Constitutional: body-wide (e.g., fever, fatigue, weight loss)
- Head, eyes, ears, nose, and throat (HEENT)
- Respiratory
- Cardiovascular
- Gastrointestinal
- Genitourinary
There are also other system assessments that are part of an extended or more complete ROS:
- Metabolic/endocrine
- Neurological
- Psychiatric
- Integumentary
- Musculoskeletal
- Hematologic
- Immunologic
The nurse will document the findings of the ROS based on whether signs and symptoms are present in each system. The term positive is often used to note when a sign or symptom is present, while negative is used when signs and symptoms are absent from a system. In some provider documentation, the “+” may be used for positive and the “−” sign for negative, with specific details pertaining to the problem within the body system. Other providers may use terms like “unremarkable” to denote an assessment that system assessment is normal.
Current Medications
When reviewing the patient’s medical record, it’s important to note that the medication list may or may not be up to date. It is essential that each time a patient is seen, they are asked about all medications, even OTC supplements or herbal remedies, that they are actually taking at home. If the patient has any prescribed medications, confirm the names, reasons for taking, dosages, and frequencies of each. Sometimes, patients will bring their medication bottles with them, which can be extremely helpful for medication reconciliation (AHRQ, 2019). It is also important to ascertain whether the patient has been taking medications as prescribed; in other words, it’s not enough to simply ask if the patient is taking their medication but find out how they are taking it. When a patient reports they are no longer taking a specific medication (discontinued) or there has been a change in administration (e.g., increased or decreased dose), update their record. A precise and thorough medication reconciliation assists in preventing medical errors, which in turn decreases length of stay, lowers hospital costs, and reduces readmissions (Alghamdi et al., 2023).
Social Determinants of Health
There are also sociocultural factors about which the nurse needs to gather information to provide additional context about the patient’s current health:
- Education
- Occupation
- Nutrition, diet, physical activity
- Financial status
- Environment (e.g., living, work)
- Lifestyle habits (e.g., tobacco, alcohol, substance use)
- Psychological well-being (e.g., stress)
- Spirituality
- Sexuality
- Cultural background
Including these factors ensures that the nurse has captured the details about a patient’s life that could not only be relevant to their chief complaint but could affect the treatment decisions that will come after a diagnosis is made. This sociocultural history allows for more of a narrative about the person and not only the symptom that has brought them to see the provider. Here, the nurse can grasp more about who the patient is, what their life is like, and explore how the patient perceives and feels about their general health. The patient’s social history is also an important opportunity to identify risk factors that could either be relevant to the patient’s current problem or overall well-being. Table 6.3 compares protective factors with risk factors.
| Protective Factors | Risk Factors |
|---|---|
| Strong social support network (e.g., family, friends, community) | Social isolation or lack of support |
| Stable employment and financial security | Unemployment or financial instability |
| Access to health care and health insurance | Lack of access to health care or inadequate insurance |
| Able to access and partake in health-promoting lifestyle habits (e.g., exercise, nutritious diet, sleep) | Sedentary lifestyle, lack of access to nutritious food, inadequate sleep |
| Positive coping mechanisms for stress | Negative coping mechanisms (e.g., substance misuse, isolation) |
| Engagement in meaningful activities and hobbies | Lack of purpose or meaningful engagement in life |
| Education and health literacy | Low literacy/health literacy |
| Safe and stable housing | Unstable housing or homelessness |
| No exposure to violence or trauma | Exposure to violence, abuse, or trauma |
| Spiritual or religious beliefs that provide comfort and support | Negative spiritual or religious beliefs/loss of faith, spiritual crises |