During a health history, the nurse collects subjective data from the patient, their caregivers, and/or family members using focused and open-ended questions. Before discussing the components of a health history, let’s review some important concepts related to assessment and communicating effectively with patients. Obtaining a patient’s health history is a component of the Assessment phase of the nursing process. Information obtained while performing a health history is called subjective data. Subjective datais information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance. Subjective data is considered a symptom because it is something the
patient reports. When documenting subjective data in a progress note, it should be included in quotation marks and start with verbiage such as, “The patient reports…” or “The patient’s wife states…” An example of subjective data is when the patient reports, “I feel dizzy.” A patient is considered the primary source of subjective data. Secondary sources of data include information from the patient’s chart, family members, or other
health care team members. Patients are often accompanied by their care partners. Care partners are family and friends who are involved in helping to care for the patient. For example, parents are care partners for children; spouses are often care partners for each other, and adult children are often care partners for their aging parents. When obtaining a health history, care partners may contribute important information related to the health and needs of the
patient. If data is gathered from someone other than the patient, the nurse should document where the information is obtained. Objective data is information observed through your senses of hearing, sight, smell, and touch while assessing the patient. Objective data is obtained during the physical examination component of the assessment process. Examples of objective data are vital signs, physical examination findings, and laboratory results. An example of
objective data is recording a blood pressure reading of 140/86. Subjective data and objective data are often recorded together during an assessment. For example, the symptom the patient reports, “I feel itchy all over,” is documented in association with the signof an observed raised red rash located on the upper back and chest. It is vital to establish rapport with a patient before asking questions about sensitive topics to obtain accurate data regarding the mental, emotional, and spiritual aspects of a patient’s condition. When interviewing a patient, also consider the patient’s developmental status and level of understanding. Ask one question at a time and allow adequate time for the patient to respond. If the patient does not provide an answer
even with additional time, try rephrasing the question in a different way for improved understanding. If any barriers to communication exist, adapt your communication to that patient’s specific needs. For more information about potential communication barriers and strategies for adapting communication, visit the
“Communication” chapter in Open RN Nursing Fundamentals. Cultural SafetyIt is important to conduct a health history in a culturally safe manner. Cultural safety refers to the creation of safe spaces for patients to interact with health professionals without judgment or discrimination. Focus on factors related to a person’s cultural background that may influence their health status. It is helpful to use an open-ended question to allow the patient to share what they believe to be important. For example, ask “I am interested in your cultural background as it relates to your health. Can you share with me what is important to know about your cultural background as part of your health care?” If a patient’s primary language is not English, it is important to obtain a medical translator, as needed, prior to initiating the health history. The patient’s family member or care partner should not interpret for the patient. The patient may not want their care partner to be aware of their health problems or their care partner may not be familiar with correct medical terminology that can result in miscommunication. Frequently Asked Questions What is “assessment”? Assessment is the first step in the nursing process. Assessment includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals. What is the purpose of assessment? The purpose of assessment is to establish a database about a client’s physical and emotional well-being, intellectual functioning, social relationships, and spiritual condition. What are the types of assessments? The types of assessment are (1) the comprehensive assessment; (2) the focused assessment, concentrated upon the presenting problem of the client; (3) the ongoing assessment; and (4), the emergency assessment. What is the difference between subjective and objective assessment data? Subjective data are information from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing. What is the difference between primary and secondary sources of data in assessments? A primary source of data is the person who is being examined. Secondary sources include family members/significant others; other health care professionals; the medical record; interdisciplinary conferences, rounds, and consultations; results of diagnostic tests; relevant literature; and the nurse’s knowledge and experience. What are the five methods of data collection? The five methods of data collection are observation, interview, the health history, the physical examination, and laboratory and diagnostic testing. What is the difference between open-ended, closed-ended, and focused questions? Open-ended questions are used to explore and identify problems and concerns. Closed-ended questions are questions that can be answered with one word. Focused questions are questions asked to obtain information about a problem or condition that is more specific, allowing the client to provide a response that is more than a yes or no response. What types of data are included in a health history? The health history includes demographic information; reason for seeking health care; perception of health status; previous illnesses, hospitalizations, and surgeries; the client/family medical history; immunizations/exposure to communicable disease; allergies; current medications; developmental level; psychosocial history; sociocultural history; activities of daily living; review of the systems (ROS); and health promotion activities. What are the four assessment techniques used in physical examination? The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation. What is “data verification,” and how is it done? Data verification is the process through which data are validated as being complete and accurate. Data verification consists of (1) reviewing the data for inconsistencies or omissions, (2) observing nonverbal behavior to confirm or contradict a client’s perceptions, (3) comparing data with norms, and (4) rechecking and confirming grossly abnormal findings. What are some nursing assessment models used to organize assessment data? Examples of nursing models used to organize assessment data are Marjory Gordon’s Human Functional Health Patterns, the North American Nursing Diagnosis Association (NANDA) taxonomy of nursing diagnoses, Orem’s Self-Care Theory, the Roy Adaptation Model, and the Leininger Sunrise Model. What are Gordon’s Eleven Health Patterns? The 11 health patterns in Gordon’s model are the health perception-health management, nutritional-metabolic, elimination, activity-exercise, cognitive-perceptual, sleep-rest, self-perception–self-concept, role-relationship, sexuality-reproductive, coping-stress-tolerance, and value-belief patterns. What are the four types of formats used for documentation of assessment data? The four types of formats used for documentation of assessment data are the open-ended, checklist, combination, and specialty formats. What is an example of a subjective assessment?Some examples of subjective assessment questions include asking students to: Respond with short answers. Craft their answers in the form of an essay. Define a term, concept, or significant event.
What are some examples of subjective data?Subjective data is anecdotal information that comes from opinions, perceptions or experiences. Examples of subjective data in health care include a patient's pain level and their descriptions of symptoms.
What should be included in subjective assessment?The subjective examination includes collecting information regarding age, race, gender, working status, stress levels and a current and past medical and family history.
What is considered subjective patient data?Subjective data is information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance. Subjective data is considered a symptom because it is something the patient reports.
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