HISTORY COLLECTION FORMAT

In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.

1. History collection By: R. SARAV ANAN

2. INTRODUCTION History collection is gathering of information from the patient. It is the first step in the providing care for the patient. It is one of the important step in the diagnosis of the patient condition . Through history collection hereditary disease can be identified and treated.

3. History collection format Identification data Name of the patient : Age : Sex : Identification number : Bed number : Ward : Education : Occupation : Monthly income : Religion : Nationality : Chief complaints : Diagnosis :

4. Date of admission : on Date of care start : on Present complaints : date of care end : on Name surgery : Date of surgery : on Post operative days : Date of discharge : on Socio economic status : Bread winner of family Type of family and house Monthly income of the family Facility of the family like water supply electricity , ventilation , closed drainage etc ,,, Inter personal relationship with neighborhood Pet animal.

5. Family tree Keys: Male Female patient death Name & age Name & age Name & age Name & age Name & age Name & age s.no name age sex Relationship With patient education occupation Monthly income Marital status Health status Family composition

6. Family medical history Family history of hereditary disease like diabetes mellitus or hypertension or any other hereditary diseases History of any communicable disease like leprosy or tuberculosis Or history of any congenital disorder like cleft lip and palate. Personal history Personal hygiene Like grooming, bathing, brushing, and wearing a clean cloths. Diet Belongs to vegetarian or non vegetarian and Food pattern of the patient .

7. Sleeping pattern Sleeping pattern of the patient and time duration in day and night . Elimination pattern Bowel elimination pattern Bladder elimination pattern Habit Like smoking and alcohol if it is present since how many years . Hobby Hobby like reading, writing, watching TV or playing etc ,… Allergy History of food and medicational allergy for the patient.  

8. Medical history Present medical history Name of the patient, Date and time of admission, Hospital name, Chief complaints, Diagnostic evaluation, Ongoing Treatment. Past medical history If presence of past medical history and reason of past medical history. Name of the hospital, diagnosis and treatment details are to be explained. If there is no past medical history, there is no any significant of past medical history.

9. surgical history Present surgical history Name of the surgery, Name of the surgeon, Name of the anesthesia, Name of the anesthetist, Duration of the surgery, Duration of anesthesia, No of post operative days are should be explain . Past surgical history Name of the surgery, Year of surgery, Surgery name, Any complication of surgery.

10. Thank you