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English 101


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Developing a Personal Health Record

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Undergrad. (yrs 3-4)
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Undergrad. (yrs 3-4)
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    What is Comprehensive Health History?

    What is Comprehensive Health History?

    One of the most common questions is: What is a comprehensive health assessment? Comprehensive health history is the collection of information about a patient’s medical, social, family, and psychological history. The process of comprehensive health history includes gathering subjective data through face-to-face interviews with the patient as well as objective data by chart review after which an assessment is made of their risk to illness or injury based on perceived priority. An appreciation for the patient’s life, health beliefs and practices, body image, family life style, spirituality, educational level, occupation and social status helps in designing individualized programs that are integral to achieving better healthcare outcomes.

    The concept of comprehensive health history has been described as “the result of an attempt by physicians in the United States to develop a standardized nursing process for comprehensive patient assessment.”

    Factors that Influence the Development of Holistic Nursing Model

    A number of factors have influenced the development of holistic nursing model, starting from Florence Nightingale in 1859 to the writings by Michael Balint, an English physician. These are the components of a comprehensive health history. The concept has been used in various other health care settings, although its application has not yet been extended to all areas of nursing. Nightingale, who is considered to be the founder of modern nursing, advocated for holistic care in hospitals during the Crimean War. Furthermore, Balint’s writings were instrumental in developing a holistic approach to individual patient assessment within primary health care settings before it was adapted by nurses and became known as the nursing process.

    The second factor that influenced the development of holistic nursing model is nurse-midwifery care. As such, during this time, nurses played a major role in providing the holistic prenatal and postnatal care for women empowering them to make informed choices about their healthcare. The traditional nursing process was also refined by Linda Aiken and colleagues during this period. They challenged the use of the traditional nursing process in primary care, arguing for a more comprehensive patient history to be taken before undertaking the physical assessment.

    The third factor that influenced the development of holistic nursing model is increased use of technology in health care. This has led to “information overload” which results in large amounts of data being collected by nurses during physical assessments. To manage this information overload, nurses began using various methodologies to ensure that they were able to collect the relevant data.

    The fourth factor is the World Health Organization (WHO) definition of health and its implication for nursing practice. This model promoted a global approach to patient care where every person recognized as being a nurse should be competent in providing holistic care to every person, regardless of their age or health status.

    Purpose of Obtaining Comprehensive Health History

    What is the purpose of obtaining a patient’s comprehensive health history?

    The purposes of comprehensive health history include:

    1. Helping the nurse to define and prioritize problems that require assessment;

    2. Identifying factors that may interfere with plan implementation; and,

    3. Determining the patient’s health status and well-being: physical, psychological, social, spiritual, and environmental factors.

    The purpose of the comprehensive health history is to ensure that nurses have a greater understanding of their patients’ life experiences in order to provide holistic care. Holistic nursing is defined as “a philosophy in which the nurse recognizes the spiritual, emotional, physical, and social needs of each individual patient.”

    In addition, when there is an illness or injury, nurses are looking to provide holistic care for all types of patients. Nurses must consider the family and individual factors which influence health beliefs before providing an appropriate standard of care. Furthermore, patient assessments should be designed to target these health beliefs.

    How should a comprehensive health history be documented?

    A detailed documentation of the health history should be included in the patient’s medical record. It is important that all health related information be included within each of these documents. Here is a comprehensive health history example.

    The objective data collection activities should include:

    1. Demographic data,

    2. Personal and family health history,

    3. Social support system, and

    4. Current life situation.

    Subjective data should include:

    1. Relevant subjective elements such as: psychosocial assessment, personal and family coping strategies developing a plan of care, positive and negative beliefs about health/illness etc., and exploring the patient’s expectations for their own recovery. This information can help to develop a holistic nursing diagnosis for each patient.

    In order to write an accurate and comprehensive health history, the nurse needs to use proper documentation skills including:

    1. Writing from left to right as well as from top to bottom for a complete record,

    2. Use standard abbreviations or words that are clear and concise,

    3. Include all relevant information on the health history,

    4. Clearly label sections of the record,

    5. Avoid making assumptions, and

    6. Limit personal comments to a minimum.

    These details make for a comprehensive health history template

    What are some errors that can be made when taking a patient’s comprehensive health history?

    Some of the most common errors that are made include: not asking all pertinent questions, rushing the interview process, not asking follow-up questions, jumping to conclusions or making assumptions about patients’ responses, and documenting inaccurately.

    Nurses should avoid these errors by slowing down the assessment process and taking time to listen to patient’s responses. This will help them to obtain a more accurate understanding of their patient’s life experiences which will ultimately benefit them in their nursing care.

    Nurses are expected to have the knowledge, skills, values and attitudes to provide holistic care for all patients regardless of age or health status. Nurses who demonstrate this commitment will be able to assist their patients by giving them the right amount of information, at the right time in a culturally sensitive manner.

    Nurses are creating new policies to ensure that they are using ethical decision-making in their practices. This is particularly true with the use of complementary and alternative medicine (CAM). The importance of comprehensive health history cannot be overstated as nurses must provide a complete health history example.

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