Deck 4: The Complete Health History and Mental Status Assessment

Question 1

State the purpose of the complete health history.

Answer 1

Collection of subjective data or learning what a person says about himself or herself is the purpose of the health history. By combining the subjective information with objective information obtained through the physical examination and relevant diagnostic studies, the health care provider strives to view the patient as a whole person functioning within the environment. The data are used to make a judgment about the health status of the person.
The health care provider conducting the interview must also keep in mind that others will refer to his or her documentation. Completeness, accuracy, and clarity of the recording will assist all who refer to the patient's record.

Question 2

List the categories of information contained in a health history.

Answer 2

Although the form itself may vary among health care settings, the following information is usually obtained: biographic data, source of history, reason for seeking care, current health or history of current illness, past health, family history, review of systems, and functional assessment, including activities of daily living (ADLs). It should be noted that in the past the reason for seeking care was referred to as the chief complaint, and this term may still be noted when one is reading health histories written by other health care providers.

Question 3

Describe the data or information that must be gathered for each category of a health history.

Answer 3

Because the health history, combined with objective data obtained through physical examination and diagnostic studies, provides the base on which a judgment or diagnosis regarding the health status of the individual is made, obtaining accurate and complete information is critical. Although the depth of information obtained for each category may vary from one setting to another, all must be addressed before a diagnosis is made. The categories addressed in a health history are listed in the Performance Checklist.

Question 4

Describe the eight characteristics included in the summary of each patient symptom.

Question 5

Relate developmental care during a health history for a child or older adult.

Question 6

Define the behaviors that are considered in an assessment of a person's mental status.

Question 7

Describe relevant developmental care related to the mental status examination.

Question 8

State the purpose of a mental status examination.

Question 9

List the four components of mental status assessment.

Question 10

Complete a Mini-Mental State Examination.

Question 11

Discuss developmental care for infants, children, and aging adults.