Examples of health history

I need you to be very specific.  If you do not address everything in the list, the reader will not know that you asked.

For example:

Chief complaint: this needs to be in the client's own words with quotation marks:

  • Chief complaint: none  (zero points)
  • Chief complaint: headache (1/2 point)
  • Chief complaint: "I've had a headache for 3 days. Nothing seems to help it." (1 point)
  • Chief complaint: "I'm helping you with an assignment." (1 point)

Another example

Other Hospitalizations: (1)

If you said   Other Hospitalizations: none  (zero points)

If you said: Other Hospitalizations: pt denies (1/2 points)

If you said:  Denies any previous hospitalizations.  (one point)

If you said:  Patient reports being hospitalized 2 years ago for heat exhaustion.  Patient was working construction during 99 degree F temperature. Was dizzy, nauseated and vomiting.  Was treated with IV fluids during short term stay. Discharged with no residual effects.  (1 point)

Another example:

Habits: smoking, alcohol, caffeine (1)

If you said:  Habits: smoking alcohol, caffeine: none (0 points)

f you said: Habits: smoking alcohol, caffeine: pt denies (1/2 points)

If you said:  Habits: smoking alcohol, caffeine: Denies smoking, alcohol or caffeine intake or Denies smoking.  Reports drinking 2 cups of coffee every morning. Client states he drinks 2 beers per week (one point)

 

 Hope this helps.  If it is unclear what I want, please send me an e-mail or phone.