2.2 Health History

The purpose of obtaining a health history is to gather data from the patient and/or the patient’s family, so the healthcare 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 or a care agency, or with initial contact with community nursing services, but a health history may be taken whenever additional information 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 symptoms described by the patient that are 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. Checklist 13 provides a guide for obtaining subjective data during a health history.

It should be noted that the theoretical underpinnings of the different components of a health history are beyond the scope of this textbook. However, the nurse should remember that using open-ended questions allows the patient to direct the interview and may reveal information otherwise missed through closed-ended questioning.

Objective data is information that the healthcare professional gathers during a physical examination and consists of information that can be seen, felt, smelled, and/or heard by the healthcare professional. When taking a health history, data obtained through diagnostic means (i.e., vital signs, blood work, chest x-ray, etc.) may be used by healthcare professionals to understand the client’s health status.

Critical thinking is necessary to interpret and evaluate the assessment findings, and to use this to inform nursing judgement. The data gathered in a health history provides the healthcare professional an opportunity to assess health promotion practices and offer patient education (Stephen, Skillen, Day, Jensen, 2012).

It should be noted that although agency forms may differ slightly, all health histories should include main components similar to the ones listed in Checklist 13.