NSG 2317 Chapter Notes - Chapter 5: Ear Pain, Palliative Care, Mnemonic
15 Dec 2016
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In documenting the history, the nurse should recognize and affirm what the patient is doing right- what they are doing to stay well. For a well patient, the health history is used to assess their overall health status, health maintenance goals, and health promoting practices such as exercise, healthy diet, etc. For the ill patient, the health history includes a detailed and chronological record of the health problem. For all patients, it is a tool used for screening abnormal symptoms, health problems/ concerns, and it records ways of responding to health problems. Record who provides the information: usually the patient themselves, a parent, or in some cases a relative or a friend. Judge how reliable the informant seems and how willing he or she is to communicate. A reliable patient always gives the same answers, even when questions are rephrased or repeated at a later time. Note any special circumstances, such as the use of an interpreter.
