How can we identify health risks, strengths, and needs in our comprehensive health assessment?
To identify health risks, strengths, and needs during a comprehensive assessment such as during a routine annual physical, or during a new hospital admission, a complete and detailed health history must be conducted. A comprehensive and all-encompassing patient health history will give the provider insight into what has happened in the past (past diseases and illnesses), what is currently going on with the patient (current medical conditions being treated), and possibly predict and prevent future complications (diagnosis and disease prevention) (Nichol, 2022). Gathering a health history will also allow open communication between the patient and provider and help build a trusting relationship for better outcomes (Bickley, 2023). key components in the health history include chief complaint, history of present illness, past medical history, allergies, medications, social history, family history, health promotion and maintenance, and review of systems (Nichol, 2022).
Give two examples with a rationale for each.
Gathering information on the patient’s social history can assist providers in assessing the patient’s risk factors and help guide their care plan for better outcomes (Bickley, 2023). A patient’s social history can give insight into the patient educational level, financial and economic status, alcohol and tobacco use, illicit drug use, immunization status, sexual history, family history, religious affiliation, household composition, relationship status, and safety (Bickley, 2023). Having this information can help providers identify risk factors that may add to preexisting conditions and help prevent the onset of new conditions (Bickley, 2023). It is also important to know certain personal social history information such as the patient’s financial status, living situation, and home safety situation since this can allow the provider to know if the patient has access to health care, can afford medication, has access to fresh food, and if the patient is a victim of abuse, and provide the patient with the appropriate resources and help (Bickley, 2023).
2-Review of systems
The review of systems can give an in-depth overview of each system of the body uncovering information that may have been missed or left out by the patient or provider (Bickley, 2023). Asking detailed yes and no questions about each body system can uncover systemic issues and clues that may lead to a more accurate and precise diagnosis and treatment plan (Bickley, 2023). Although the type of questions asked in the review of systems are not related to the HPI, providers may discover symptoms that are majorly related to the chief complaint, therefore these symptoms should be a part of the patient’s HPI (Bickley, 2023).