Assessment and Diagnosis · 4 min read
Health History Collection
The health history is the foundation of assessment. It captures information that examination and testing cannot provide: the patient's perspective, risk factors, baseline function, and goals. The interview also builds the therapeutic relationship, so the nurse uses open-ended questions, active listening, and a nonjudgmental approach that encourages full disclosure.
Components of a Comprehensive Health History
| Component | Content | Nursing focus |
|---|---|---|
| Biographical data | Age, occupation, living situation, preferred language, support persons | Context for risk, literacy, and discharge planning |
| Chief complaint | Reason for seeking care in the patient's own words | Record verbatim; it directs the rest of the interview |
| History of present illness | Detailed analysis of the chief complaint (OLDCARTS) | Characterize every symptom completely |
| Past medical history | Chronic illnesses, hospitalizations, surgeries, injuries, immunizations, screenings | Identify conditions that change risk or treatment |
| Medications and allergies | Prescriptions, over-the-counter drugs, supplements, herbals; nature of each reaction | Reconcile the list; distinguish true allergy from intolerance |
| Family history | Health of first-degree relatives and age at onset; three-generation pedigree when indicated | Early-onset disease suggests a stronger genetic component |
| Social history | Tobacco, alcohol, substance use; diet; activity; sexual health; occupation; housing; finances | Quantify use; screen for social determinants of health |
| Review of systems | Head-to-toe symptom inventory | Safety net for symptoms not yet mentioned |
| Functional assessment | ADLs, IADLs, mobility, falls, cognition | Establish baseline for planning and discharge |
History of Present Illness: OLDCARTS
| Letter | Element | Example question or clinical meaning |
|---|---|---|
| O | Onset | "When did it start, and was it sudden or gradual?" Sudden onset suggests an acute event such as pulmonary embolism or myocardial infarction. |
| L | Location | "Point to where it hurts. Does it travel?" Radiation suggests nerve involvement or referred pain. |
| D | Duration | How long each episode lasts and how long the problem has been present. |
| C | Character | Sharp, dull, burning, pressure, cramping. Sharp pain suggests somatic structures; dull or aching pain suggests visceral involvement. |
| A | Aggravating factors | Movement, position, eating, breathing, exertion. |
| R | Relieving factors | Rest, position change, medication, heat, or cold; also offers diagnostic clues. |
| T | Timing | Constant or intermittent; time of day; relation to meals or activity. |
| S | Severity | 0-to-10 rating; trend over time indicates progression or improvement. |
Medications, Allergies, and Reconciliation
Medication reconciliation compares the medications the patient actually takes with admission, transfer, and discharge orders to prevent omissions, duplications, and dosing errors. The best source is the patient's own containers or pharmacy records, verified with the patient. For every reported allergy, document the specific reaction: hives, wheezing, or angioedema indicate an immune-mediated allergy, whereas nausea or dizziness usually indicates an intolerance or side effect.
- Ask about over-the-counter products, herbals, and supplements separately; patients often do not consider them medications.
- Older adults: review every medication against the Beers Criteria for drugs that increase confusion, falls, and bleeding.
- Document the reaction, not just the word "allergic."
Social History and Screening Tools
| Topic | How to quantify or screen |
|---|---|
| Tobacco | Pack-years = packs per day × years smoked (1.5 packs/day for 30 years = 45 pack-years). Ask about e-cigarettes and smokeless tobacco. |
| Alcohol | AUDIT-C or CAGE. A CAGE score of 2 or more (Cut down, Annoyed, Guilty, Eye-opener) is clinically significant. Heavy drinking: more than 4 drinks per day or 14 per week for men; more than 3 per day or 7 per week for women. |
| Other substances | Ask about each substance, route, and frequency in a nonjudgmental manner. |
| Nutrition and activity | 24-hour recall, recent weight change, appetite, exercise frequency and intensity. |
| Social determinants | Housing stability, food insecurity, transportation, ability to afford medications, caregiver support. |
| Safety | Falls in the past year, intimate partner violence, elder mistreatment, firearms in the home. |
Review of Systems
The review of systems is a structured inventory of symptoms by body system: general (fever, weight change, fatigue, night sweats), skin, head, eyes, ears, nose and throat, neck, respiratory, cardiovascular (chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema), gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, endocrine (heat or cold intolerance, polyuria, polydipsia), and hematologic. Every positive finding is explored with OLDCARTS.
Special Populations
- Record the chief complaint in the patient's own words.
- Pack-years = packs per day × years smoked.
- Document the nature of every allergic reaction; distinguish allergy from intolerance.
- Infection or medication toxicity in an older adult may present only as new confusion or falls.
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