Health History Documentation Question

  1. Hi, I am working on a health history for my health assessment class. I am quite confused about what information goes in the "Client Profile" portion of the health history form, or more importantly the wording. Does the client profile basically just have the clients age, concern today, medications, past illnesses or surgery, previous hospitalizations, drug allergies etc? It seems much like subjective that the case?

    Also, anyone have any good websites that offer information on these basics of nursing?

    Thank you,
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    About PennyNickelDime_RN

    Joined: Jun '03; Posts: 277; Likes: 45
    RN - Emergency Department
    Specialty: Oncology, Emergency Department


  3. by   ICRN2008
    For our assignment we had to include the following in client data:
    Name, birthdate, birthplace, address,telephone, marital status, race, occupation, usual source of healthcare, source and reliability of information, today's date, reason for visit or chief complaint, present health status or present illness. Then for past history, we had childhood illnesses, major illnesses, surgeries, allergies, current medications, injuries, habits, family health history, nutritional data, psychosocial history, and review of systems. I used my textbook for the assignment, because it had an example of a health history. It is all subjective, client-reported data. Hope this helps and good luck.
    Last edit by ICRN2008 on Nov 6, '05