Slide 1 Comprehensive Health History By Dr. Traci Richards Burks Slide 2 Definition of Health History -a collection of information obtained from the client Narrative: Health history is basically a collection of information obtained from the client, the client’s family and significant others, and from other sources (such as hospital records, other healthcare providers’ records, and referral sources) concerning the patient's physical status as well as his or her psychological, social, and sexual function. Slide 3 Purpose of the Health History -provides a database Narrative: The health history provides a database on which a diagnosis, a plan for management of the diagnosis, treatment, care, and follow-up observation of the client may be made. Slide 4 Parts of the Health History • Identifying data Describes the client Narrative: The identifying data include information about the client’s age, gender, race, culture identity, occupation, marital status, religious preference, and health beliefs. Slide 5 Parts of Hx (con’t) • Source of the History Who gave the history? Narrative: The client is usually the person who gives the adult history. Parents are usually the person who give the history of children (adolescents are expect to give their history which may be conferred with the attending parent). If the client is impaired cognitively or have speech impairments, other support persons may give the information. These people are documented in your report. For example, you will write: The client is the source of the information. Slide 6 Parts of Hx (con’t) 1 • Reliability of the Source Narrative: In this section, you will discuss whether the provider of the information is reliable. If the client is unreliable, describe the factors that are causing the problem (i.e., memory loss, language/communication issues, trust issues, mood, pain, etc.), Slide 7 Parts of Hx (con’t) Source of Referral: How did the client learn about you clinic (such as a family member or friend, telephone or internet ads) or who sent them to you (such a referral from another provider)? . Narrative: Source of referral includes information regarding how the client learn about your clinic or who sent them to your clinic. You may need to express your appreciations to this individual and the same time you will know that your ads or working. Parts of Hx (con’t) Slide 8 • Chief Complaint(s) Why did the client come to the clinic? Narrative: The chief complaint is a statement that explains the reason(s) the client came to the clinic or hospital. The complaint(s) should be written in the client’s own words. Therefore, the provider must ask a direct question that will require them give the answer. For example, you may ask the question as: what brought you into the clinic today? What problems are you having today? Then, the client will say something like: “I have had a bad headache for the past two days.” You will write the client’s words as you would write a direct quote along with quotation marks. Other reasons can include the following: looking for a new doctor, need of a physical for employment, school, athletic/sports. Slide 9 Parts of the Health Hx (con’t) • History of the Present Illness Describes the characteristic of the chief complaint Narrative: The history of the present illness describes the signs and symptoms, onset and character; and any factors or behaviors that aggravate or relieves the symptoms. These will medications, activity level, non-medication therapies, OTCs, herbs, natural treatments, and home remedies. The patient's own words should be quoted. Slide 10 Parts of the Health Hx (con’t) • Past Medical History - Includes the following subheadings: 2 o Allergies o Childhood illnesses Narrative: All types of allergies should be listed including foods, meds, plants, and other items. List all childhood illnesses, the age that the disease was acquired, and any complications related to the disease. Parts of the Health Hx (con’t) o adult illnesses o surgeries o hospitalizations Slide 11 Narrative: All adult illnesses should be listed including the age that the disease was acquired and any complications associated with the disease. List all surgeries the client has had with the dates, hospital, the surgeon, and complications related to the surgery. Finally, list all medical and psychiatric hospitalizations including purpose, locations, dates, and the name of the admitting/attending physicians. Parts of the Health Hx (con’t) o transfusions o medications Slide 12 Narrative: All transfusions should be listed along with the purpose, date, and complications. All medications should be listed including prescriptions, OTCs, herbs, roots, and home remedies. State the purpose for taking the drug, dosage, frequency, drug store, prescriber, and perceived effectiveness. Parts of the Health Hx (con’t) Slide 13 • Health Maintenance-Promotion Practices o o o o Immunizations Screening tests Life-style Home safety including domestic violence Narrative: List both childhood and adult immunizations and any associated complications. List screening test such as mammograms, PAP smear, PSA, along with the dates taken and the results. Life-style refers to behaviors that promote wellness such as diet, exercise routine, driving with seat belt, safe sex practices, birth control, dating habits, and so on. Home safety includes the use of smoke alarms. 3 Home safety includes having smoke, carbon monoxide, floor, and burglar alarms. It also includes dangerous drugs, chemicals, and others in the reach of children and impaired adults. Issues surrounding electric outlets and wiring safety, plumbing issues, gas issues, and other areas that cause destruction to the home and other properties. Domestic violence includes verbal, physical, psychological, and sexual abuse in the home. Include any legal actions taken, describe who is the perpetrator, and preventive measures (such coping methods and counseling). Slide 14 Parts of the Health Hx (con’t) • • Occupational Hx Family Hx Narrative: An occupational history, describing the patient's work and exposure to stress, toxins, radiation, or other occupational hazards, may be included. The effect of the current illness on the patient's work is also noted. The examiner will diagram or outline a family tree including siblings, parents, and grandparents indicating their ages, health statuses, any deaths with age and cause of death. Document the presence or absence of specific diseases (HTN, DM, Strokes, Cancers, and other diseases that may have a genetic cause). Also, describe the family of origin (or family roots such as where did the family begin, country, part of the US, where do the closest family members live), description of the client household. Slide 15 Parts of the Health Hx (con’t) • • Personal Hx Social Hx Narrative: Personal Hx includes sexual preference(s), habits, and interest. A social history is taken in which the patient's social, cultural, environmental, and familial milieu are outlined, focusing on aspects that might have an effect on the current illness. In some instances a sexual history may be relevant. Slide 16 Parts of the Health Hx (con’t) • Review of Systems (ROS) Narrative: Describe the presence or absence of common symptoms of specific disease by systems from head-to-toe. Slide 17 Types of Health Assessments Relevant to this Course 4 • • Comprehensive Episodic Narrative: A comprehensive health history is usually done with a new client. It includes everything that we just covered from a history of the chief complaint, present illness, past and present health history, social history, occupational history, sexual history, family health history and ending with the ROS. A comprehensive health history is scheduled for extended time such as one-hour or so. The client is bill for an extended visit. An episodic health history is usually done on an established client or in an emergency situation (in this case it will be completed at the next scheduled visit). It is also a kind of health history that notes the general condition of a client during the period between visits and it includes follow-up visits and new complaints/problems. The episodic health history provides an ongoing account of a person's health, serving to bring the data base up to date. It is also referred to as a periodic or interval health history. Slides 18 & 19 Instructions for Assignments • • • • • Select a person for your Comprehensive History Do not use any true identifying data for any of your clients Use the narrative format for the Comprehensive Health History Documentation Do not collect any objective data, do not make any assessment/diagnoses, and a plan. Try to complete the assessment in one hour. . Narrative: You are ready to collect and document the data for a comprehensive health assessment. Since you have not been approved to a clinical site at this point, you may select anyone you know who is willing to help you with this assignment (family members, friends, coworker, and church members). We must keep this person’s and the client’s in the clinical setting data private. You must give fake names (such as Mr. John Doe) and do not use data that will identify the client. Slide 20 I would like to wish you the best of luck with project. 5 Diagnostic and Clinical Reasoning Paper Although students are required to submit patient SOAP notes weekly in Typhon this assignment will allows students to further develop and demonstrate their diagnostic and clinical reasoning competency skills. Students are to choose an actual patient they saw in the clinical setting to develop this paper. The patient chosen for this paper should reflect a more complex patient seen in clinical practice that address the population addressed in this course. The paper should be written using APA format. Introduction The SOAP note (an acronym for subjective, objective, assessment, and plan), is a format of documentation employed by many health care providers to document their patient encounters. Professional documentation of patient encounters in the medical record is an integral part of practice and is also an essential component for proper billing and reimbursement. The SOAP format is one method of providing a logical analysis of data, which is consistent throughout. For example, S (subjective) and O (objective) data are all addressed and linked into the A (assessment); and all A’s (assessments) are addressed and linked into the P (Plan). The entire SOAP is directed for some “Chief complaint” (CC), or reason you are examining the patient, such as the need to complete an assessment for the patient record. The SOAP note format can be used for all types of patient encounters including an episodic or focused health concern, chronic illness follow up, or a full history and physical examination. When addressing a chief complaint (CC) for an episodic (focused) visit, an abbreviated exam (S and O) often is undertaken; if a more extensive data base is being collected (such as for a full history and physical), a more extensive exam may be undertaken. Key Points • This SOAP note format is reflective of a more extensive patient note than is typically completed in a clinical setting. However, this assignment/tool allows the student the opportunity to demonstrate their level of achievement of clinical and diagnostic reasoning. • The final section of your note summarizes your critical thinking and decision making skills for that particular patient encounter and is a mandatory additional requirement of this assignment. It provides the student an opportunity to demonstrate the thought process used in caring for the patient. Components of the SOAP note Title Page: (Page 1) Include Medical Diagnosis, Student Name, and Date submitted per APA format. Subjective: (Start of Page 2) CC: chief complaint: What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased. HPI: history of present illness: Use the “OLDCART” which may facilitate obtaining all necessary data. O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary 1 PMH (Past Medical History): This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known. Health Maintenance/Promotion: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. ROS: review of systems: This is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych: Objective: PE (Physical Exam): either limited for a focused exam or more extensive for a complete history and physical assessment. This area should confirm your findings related to the diagnosis. For acute 2 episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical examination of CV and lungs. This information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. Gen: general statement of appearance, if there is any acute distress. VS: vital signs, height and weight, BMI Skin: HEENT: head, eyes, ears, nose and throat Neck: CV: cardiovascular Lungs: Abd: abdomen GU: genito-urinary Rectal: PV: peripheral vascular MSK: musculoskeletal Neuro: neurological exam Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc) Assessment (number each diagnosis): • Medical Diagnosis: Start with the presenting complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up. Plan (number each plan specific to each diagnosis): These are the interventions that relate to the above diagnosis and address the following aspects (they may be included in one paragraph or separated out as listed below): Diagnostic: labs, diagnostics Therapeutic: changes in meds, skin care, counseling Educational: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling 3 Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. Clinical Decision Making The final section summarizes your critical thinking, decision-making and diagnostic reasoning skills and is a mandatory additional requirement of this assignment. It is a reflection of the thought process you used in caring for the patient. Follow the directions under each section and label each area as appropriate. ALL information should be in your own words. Do not cut and paste information obtained as this is considered academically dishonest. Pathophysiology: (1 paragraph) Include information in regards to the pathophysiology related to the main diagnosis or illness process. This will help to understand how the S and O supported this diagnosis. Leadership / Professional Role: Identify the specific person that drove this plan of care and developed the management, while including detail in how you advocated for the patient. Also include how you identified your advocacy for the role of the Nurse Practitioner. Include how an individualized approach was applied to this patients care. Barriers of Care Identify any barriers you encountered or foresee with this patients care. Demonstrate knowledge of healthcare policy and advocate for quality health care for all citizens. It is important to keep up to date with health care policy in order to provide quality patient care. This information may be obtained in journals, blogs, media, etc… Ethical and or Cultural Concerns: Identify any ethical or cultural issues related to this patients care. Include how these concerns were addressed. Pharmacology information (1 paragraph): Choose one drug that was prescribed at this visit or that is taken chronically by the patient to review. Please include the name of the drug (generic and brand), class, action, excretion, side effects and interactions, why this particular drug is being prescribed for this particular patient, what is this drug intended to treat, (specifically antibiotics, what organisms are we treating?). What other drug could be chosen instead that would work? Keep in mind the cost and convenience for the patient. This should be about a paragraph in length stated in the way that you would use to educate your patient regarding the medication. It is not acceptable to copy and paste from your pharmacology resource or text. Please cite resources used. Critical Thinking / Clinical Decision Making: (1 paragraph) In this section, include the top 2-3 differential diagnosis. This is an area that you would want to discuss what led to the diagnosis and how you ruled out certain other differential diagnosis. You may want to include why a particular treatment was chosen, perhaps despite what the books and references say. You need to provide evidence that you are referring to your available resources and 4 not just deferring to your preceptor. Address any personal biases related to aging, development, and independence that might interfere with delivering quality of care. Evidence based practice (1-2 paragraphs) Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps; • Formulating a well-built question • Identifying articles and other evidence-based resources that answer the question • Critically appraising the evidence to assess its validity • Applying the evidence • Re-evaluating the application of evidence and areas for improvement In this section please include APA citation for all resources utilized that informed your decision making with this particular patient case. In addition, describe what clinical questions and terms used to direct your search and address how valuable the evidence you found was in understanding, and directing the care. Critique (1 paragraph) This is an area where you look over the data gathered and after a careful review of the available resources (i.e. text books, reference readings) will provide a reflection of what might have been added or deleted that would have made this note more conclusive or complete. This is not an area to critique the preceptor. What areas could you have changed? What areas might you have added, perhaps additional questions you should have asked in the ROS, or additional areas you may have assessed for in the PE? Reference Page 3/31/2016 TK 5 NU609 - Advanced Health Assessment - SCRATCH 1 of 3 https://herzing.blackboard.com/webapps/rubric/do/course/manageRubric... 12/22/2016 1:38 PM NU609 - Advanced Health Assessment - SCRATCH 2 of 3 https://herzing.blackboard.com/webapps/rubric/do/course/manageRubric... 12/22/2016 1:38 PM NU609 - Advanced Health Assessment - SCRATCH 3 of 3 https://herzing.blackboard.com/webapps/rubric/do/course/manageRubric... 12/22/2016 1:38 PM
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