What it means
Information gathered by interview and records, covering current problems, past illnesses, surgeries and hospital stays, medicines (including over-the-counter and herbalER-bulMade from plants; herbal supplements are plant products taken for health, sold without a prescription.Full entry products), allergies, vaccines, family history, and social history such as smoking, alcohol, drug use, work and living situation. It is part of every admission.
For the nurse
Ask open questions, use a medical interpreterMED-ih-kul in-TER-prih-terA trained person who changes spoken or signed words from one language to another so clients and health care workers understand each other.Full entry when needed, and record allergies with the type of reaction. Check the history for conditions that change how a drug or procedure is given.
At a glance
| Spanish | historia clínica, antecedentes médicos |
|---|---|
| Also written | medical histories |
Related terms
assess
To gather information about a client by looking, listening, asking, measuring and examining.
allergy
A reaction of the immune system to a substance that is harmless to most people.
nursing assessment
A nurse's organized collection of information about a client's health, needs and responses, the first step of the nursing process.