Chapter 2. Patient Assessment
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).
Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).
The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.
| Determine the following:
1. Biographical data |
|
| 2. Reason for seeking care and history of present health concern |
|
| 3. Past health history |
|
| 4. Family history |
|
| 5. Functional assessment (including activities of daily living) |
|
| 6. Developmental tasks |
|
| 7. Cultural assessment |
|
| Data source: Assessment Skill Checklists, 2014 |
- You are taking a health history. Why is it important for you to obtain a complete description of the patient’s present illness?
- You are taking a health history. What is one reason it is important for you to obtain a complete description of the patient’s lifestyle and exercise habits?
1. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA. 1995;273(1):59–65. [PubMed] [Google Scholar]
2. Huysmans HA, van Ark E. Predictors of perioperative mortality, morbidity and late quality of life in coronary bypass surgery. Eur Heart J. 1989;10(Suppl):H10–2. [PubMed] [Google Scholar]
3. Carmon E, Keidar A, Ravid A, Goldman G, Rabau M. The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis. Colorectal Dis. 2003;5(3):228–32. [PubMed] [Google Scholar]
4. Crawford RS, Cambria RP, Abularrage CJ, Conrad MF, Lancaster RT, Watkins MT, et al. Preoperative functional status predicts perioperative outcomes after infrainguinal bypass surgery. J Vasc Surg. 2010;51(2):351–8. discussion 8-9. [PubMed] [Google Scholar]
5. Albright EL, Davenport DL, Roth JS. Preoperative functional health status impacts outcomes after ventral hernia repair. Am Surg. 2012;78(2):230–4. [PubMed] [Google Scholar]
6. KARNOFSKY DA. Chemotherapy of neoplastic disease; agents of clinical value. N Engl J Med. 1948;239(8):299–305. [PubMed] [Google Scholar]
7. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol. 1984;2(3):187–93. [PubMed] [Google Scholar]
8. Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Qual Life Res. 2009;18(7):873–80. [PMC free article] [PubMed] [Google Scholar]
9. Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8:24. [PMC free article] [PubMed] [Google Scholar]
10. Jett M, Sidney K, Blümchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13(8):555–65. [PubMed] [Google Scholar]
11. Organization WH. How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF) Exposure draft for comment. Geneva: WHO. 2013. Oct,
12. Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251–67. [PubMed] [Google Scholar]
13. Hollenbeak CS, Boltz MM, Wang L, Schubart J, Ortenzi G, Zhu J, et al. Cost-effectiveness of the National Surgical Quality Improvement Program. Ann Surg. 2011;254(4):619–24. [PubMed] [Google Scholar]
14. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531–7. [PubMed] [Google Scholar]
15. Surgeons ACo. ACS NSQIP Operations Manual. 2016.
16. Center UoMAH. Clinical and Translational Science Institute: Clinical Data Repository. 2017.
17. Kuang J, Mohanty AF, Rashmi VH, Weir CR, Bray BE, Zeng-Treitler Q. Representation of Functional Status Concepts from Clinical Documents and Social Media Sources by Standard Terminologies. AMIA Annu Symp Proc. 2015;2015:795–803. [PMC free article] [PubMed] [Google Scholar]
18. Shao Y, Mohanty AF, Ahmed A, Weir CR, Bray BE, Shah RU, et al. Identification and Use of Frailty Indicators from Text to Examine Associations with Clinical Outcomes Among Patients with Heart Failure. AMIA Annu Symp Proc. 2016;2016:1110–8. [PMC free article] [PubMed] [Google Scholar]
19. Ruggieri AP, Pakhomov SV, Chute CG. A corpus driven approach applying the “frame semantic” method for modeling functional status terminology. Stud Health Technol Inform. 2004;107(Pt 1):434–8. [PubMed] [Google Scholar]
20. Hu Z, Simon GJ, Arsoniadis EG, Wang Y, Kwaan MR, Melton GB. Automated Detection of Postoperative Surgical Site Infections Using Supervised Methods with Electronic Health Record Data. Stud Health Technol Inform. 2015;216:706–10. [PMC free article] [PubMed] [Google Scholar]
21. Hu Z, Melton GB, Moeller ND, Arsoniadis EG, Wang Y, Kwaan MR, et al. Accelerating Chart Review Using Automated Methods on Electronic Health Record Data for Postoperative Complications. AMIA Annu Symp Proc. 2016;2016:1822–31. [PMC free article] [PubMed] [Google Scholar]
22. Skube S, Hu Z, Arsoniadis E, Simon G, Wick E, Ko C, et al. Characterizing Signals for Surgical Site Infections in Clinical Notes. Studies in Health Technology and Informatics. 2017;5 [PMC free article] [PubMed] [Google Scholar]
Page 2
Karnofsky Performance Scale6,7 and NSQIP functional status scale
| 100 | No complaints, no evidence of disease |
| 90 | Able to complete major activities; minor signs and symptoms of disease |
| 80 | Normal activity with effort; some signs and symptoms of disease |
| 70 | Care of self; unable to carry on normal activities or do active work |
| 60 | Requires occasional assistance; able to care for most of personal needs |
| 50 | Requires considerable assistance and frequent medical care |
| 40 | Disabled; requires special care and assistance |
| 30 | Severely disabled; hospital admission is indicated; death not imminent |
| 20 | Very sick; hospital admission necessary and active treatment necessary |
| 10 | Moribund; fatal processes progressing |
| 0 | Death |
| NSQIP functional status scale | |
| Independent | Does not require assistance from another person for any activities of daily |
| living, including one who functions independently with the use of | |
| prosthetics, equipment, and/or devices. | |
| Partially Dependent | Requires some assistance from another person for activities of daily living |
| regardless of use of prosthetics, equipment, and/or devices. | |
| Totally Dependent | Requires total assistance for all activities of daily living. |