Chapter 2. Patient Assessment Show The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.
I. Medication Information To obtain or verify a list of the patient's current medications,b you should inquire about:
II. Medication History Prompts Incorporating various types of "probing questions" into the patient interview may help trigger the patient's memory on what medications they are currently taking. Here are some suggestions:
a Adapted from the Joint Commission Resources and the American Society of Health-System Pharmacists Medication Reconciliation Handbook. Chapter 5: Educating your staff. Oakbrook Torrance, IL: Joint Commission Resources, 2006. Return to Document Page last reviewed July 2022 Page originally created August 2012 Internet Citation: Figure 9: Tips for Conducting a Patient Medication
Interview. Content last reviewed July 2022. Agency for Healthcare Research and Quality, Rockville, MD.  What are the stages of the patient interview process?Phases of the Interview
The nursing interview has three basic phases: introductory, working, and summary and closing phases. These phases are briefly explained by describing the roles of the nurse and client during each one.
What is the best way to obtain specific information about a patient when taking the medical history?What is the best way to obtain specific information about a patient when taking the medical history? Ask direct questions that can be answered briefly. Which medical record system has a standard format that makes it easy to read and audit?
What data should the nurse collect during the interview portion of a health assessment?During an interview obtain information about a patient's physical, developmental, emotional, intellectual, social and spiritual dimensions.
What are openOpen-ended questions, which allow patients to discuss their concerns freely, are widely considered an efficient method gathering medical information from patients during a medical interview.
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During which phase of the patient interview would the nurse ask the patient about allergies and medications?
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