Open Resources for Nursing (Open RN)
After exploring a patient’s chief complaint, their current and past medical histories are reviewed to obtain a full understanding of their “human response” to medical conditions and life processes. While obtaining this information, it is also helpful to determine their understanding of the condition and its associated treatment. If a patient has a prior medical diagnosis, but is unaware of what it means or does not understand the recommended treatment, they may not be following instructions intended. For example, a patient diagnosed with “high blood pressure” may erroneously think they only need to take their medications when they feel as if their blood pressure is high, instead of daily at the recommended doses.
Categories included in past medical history include current health, medications, childhood illnesses, chronic illnesses, acute illnesses, accidents, injuries, and obstetrical health for females. Medication reconciliation is a comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit. Not all categories of current and past health histories apply to every patient, so only ask questions that are relevant to the patient you are interviewing. See Table 2.6[1] for suggested focused interview questions related to current and past medical history.
Table 2.6 Sample Focused Questions for Current and Past Health History
| Category | Focused Questions |
|---|---|
| Current health | What are your current goals for your health?
Are there any other issues affecting your current health or the ability to complete your daily activities? Tell me more. |
| Medications | What are your current medications, including prescriptions, over-the-counter medications, vitamins, and herbal supplements and why are you taking them (to establish the patient’s understanding of their medications)?
Do you take your medications as prescribed? Note: If the response is “no” or “sometimes,” follow up with an open-ended question such as, “Tell me more about the reasons for not taking the medications as prescribed.” |
| Allergies | Do you have any allergies to medications, food, latex, or other items?
If yes, what is your reaction? |
| Childhood illnesses | Tell me about any significant childhood illnesses that you had. Do you recall what childhood vaccines you received?
When did they occur? Were you hospitalized? Did you experience any complications? |
| Chronic illnesses | Tell me about any chronic illnesses you currently have or have experienced (such as cancer, cardiac or respiratory issues, diabetes, or arthritis).
When were you diagnosed? Do you see a specialist for this chronic illness? If so, what is their name and location? How is this condition currently being treated? How has the chronic illness affected you? How do you cope with the illness? Have you experienced any complications or disability from this chronic illness? |
| Acute illnesses, surgeries, accidents, or injuries | Tell me about any acute illnesses or surgeries that you have experienced.
Have you had any accidents or injuries? Did you experience any complications? |
| Reproductive health | For Females: When was your last menstrual period? Have you ever been pregnant?
Are you pregnant now or is there any chance of being pregnant now? Tell me about your pregnancies. Were there any issues or complications? |
| Immunizations | If a patient’s vaccination record is not included in their record:
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- This work is a derivative of The Complete Subjective Health Assessment by Lapum, St-Amant, Hughes, Petrie, Morrell, and Mistry licensed under CC BY-SA 4.0 ↵
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