Open Resources for Nursing (Open RN)
Use the checklist below to review the steps for completion of “Obtaining a Health History.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: health history agency form.
- Knock, enter the room, greet the patient, and provide for privacy.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Address patient needs (pain, toileting, glasses/hearing aids) prior to starting. Note if the patient has signs of distress such as difficulty breathing or chest pain. If signs are present, defer the health history and obtain emergency assistance per agency policy.
- Complete a health history interview, including the following components per your instructor’s instructions:
- Demographic and Biological Data
- Reason for Seeking Health Care
- Current and Past Medical History
- Family History
- Functional Health
- Review of Body Systems
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Document the health history findings and report any concerns according to agency policy.
