Question for an RN

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this might be a dumb question...I know you should document pertinent negatives in a pt health history. is it necessary to also document pertinent positives?

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Specializes in SICU, trauma, neuro.

That would be the bulk of the health history, no? The pt DOES have a hx of a stroke, DOES have a hx of gastric bypass, DOES have a hx of depression etc.

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The only positive thing we ask on admission paperwork is what the patient's goal is. That's it.

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The only positive thing we ask on admission paperwork is what the patient's goal is. That's it.

The phrase "pertinent positive" has nothing to do with how the question is phrased, but rather how the patient answers any relevant question about his/her health, or any relevant "finding" upon assessment.

Pert. pos = something the patient "has" or "admits" either in history, review of systems, or in assessment findings that is relevant to the situation at hand.

Pert. neg. = something the patient "doesn't have" or "denies" either in history, review of systems, or assessment findings, that is relevant to the situation at hand.

Example:

Pt comes to ED with leg pain and is concerned about DVT

Pertinent positive: Pt reports hx of DVT

Pertinent positive: Pt began an exercise regimen 2 days ago and both legs feel sore/achey

Pertinent negatives: No erythema, warmth, swelling noted in either leg; (-) Homan's sign bilat.

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The phrase "pertinent positive" has nothing to do with how the question is phrased, but rather how the patient answers any relevant question about his/her health, or any relevant "finding" upon assessment.

Pert. pos = something the patient "has" or "admits" either in history, review of systems, or in assessment findings that is relevant to the situation at hand.

Pert. neg. = something the patient "doesn't have" or "denies" either in history, review of systems, or assessment findings, that is relevant to the situation at hand.

Example:

Pt comes to ED with leg pain and is concerned about DVT

Pertinent positive: Pt reports hx of DVT

Pertinent positive: Pt began an exercise regimen 2 days ago and both legs feel sore/achey

Pertinent negatives: No erythema, warmth, swelling noted in either leg; (-) Homan's sign bilat.

My bad, can you tell I just came off a long and exhausting shift? Haha.

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Specializes in Psych (25 years), Medical (15 years).

Coming from Psych, we standardly chart positives on Patients as part of the admission evaluation process: Treatment compliance history, for example.

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