What it means
The interview part of an assessment. It usually covers the reason for the visit, the history of the present problem, past illnesses and surgeries, medicines and allergies, family history, and social history such as work, home, smoking, alcohol and drug use. The client is the main source, but family members and records may add to it.
For the nurse
Find a private, quiet place, use open-ended questions, and use a trained medical interpreter when needed. Ask about over-the-counter drugs and herbal products as well as prescriptions.
At a glance
| Also written | health histories |
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Related terms
assess
To gather information about a client by looking, listening, asking, measuring and examining.
physical examination
A head-to-toe or focused check of the body using looking, feeling, tapping and listening.
open-ended question
A question that cannot be answered with just "yes", "no" or one word, so the person explains in their own words.