2.1 Health History Collection

The Patient Interview

The health history is the single highest-yield assessment skill you bring to the MEDSURG-BC exam, because Domain I (Assessment and Diagnosis) is 49 of the 125 scored questions (39%). Before you touch the patient, the interview sets the trajectory of the entire workup.

Interview Technique

A therapeutic interview moves through four phases: pre-interaction (review the chart before entering), orientation (introduce yourself, establish privacy, state the purpose), working (gather data), and termination (summarize and invite final concerns). Core technique rules the exam loves to test:

• Open-ended questions first ('Tell me what brought you in today'), then closed-ended questions to pin down specifics ('Does the pain wake you at night?')
• Active listening: sit at eye level, lean in, allow silence, use minimal encouragers; do not chart on the computer with your back turned
• Avoid leading questions ('You don't drink much, do you?'), medical jargon, and asking multiple questions at once
• Nonjudgmental, matter-of-fact tone for sensitive topics (substance use, sexual history, intimate partner violence)
• Interview the patient, not the family, whenever the patient is able to speak; family input is collateral data, not a substitute

Chief Complaint Analysis: OLDCARTS and PQRST

The chief complaint should be recorded in the patient's own words. Then analyze the symptom systematically with OLDCARTS:

For pain specifically, PQRST is the classic alternative: Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Exam trap: severity (0-10 scale) is the least diagnostically useful element — character and radiation pattern discriminate cardiac from musculoskeletal chest pain far better. Associated symptoms matter clinically: chest pain with diaphoresis and nausea demands escalation regardless of a '5/10' rating.

Medication Reconciliation

Medication reconciliation is the formal process of creating the most accurate list possible of all medications a patient takes and comparing it against new orders at every transition of care — admission, transfer, and discharge. The complete list must include:

• Prescription medications (name, dose, route, frequency, last dose taken)
• Over-the-counter drugs (aspirin, NSAIDs, acetaminophen)
• Vitamins, herbals, and supplements (St. John's wort, ginkgo, garlic, ginseng — many interact with anticoagulants and anesthetics)
• Patches, inhalers, eye drops, and injectables patients forget to count as 'medications'

The brown bag review — asking the patient to bring every bottle from home — is the gold standard because memory-based lists are notoriously inaccurate. Document the last dose of anticoagulants, insulin, and opioids; this drives perioperative and inpatient management.

Allergies and Adverse Reactions

Always document the drug and the specific reaction. Distinguish a true allergy (immune-mediated: hives, angioedema, anaphylaxis) from an adverse effect (predictable, dose-related: nausea from opioids) or intolerance (stomach upset). A patient who 'can't take' codeine because of nausea is not allergic — mislabeling eliminates useful drug options. Also screen for latex allergy (risk factors: spina bifida, repeated catheterizations, health care workers) and food allergies that predict drug reactions (e.g., egg/soy allergy considerations with propofol).

The Rest of the History

• Past medical/surgical history: chronic illnesses, hospitalizations, prior surgeries and complications (especially anesthesia reactions — malignant hyperthermia family history is critical)
• Functional history: baseline mobility, assistive devices, activities of daily living, fall history
• Family history: first-degree relatives with cardiac disease, cancer, diabetes, stroke, anesthetic complications
• Social history: tobacco (pack-years), alcohol (amount and frequency), illicit substances, occupation, living situation, support system, sexual history, advance directives

Health Literacy Screening

Roughly 9 out of 10 U.S. adults have difficulty with health literacy at some point, and low literacy correlates with medication errors and readmissions. Validated tools include the Newest Vital Sign (a 6-question ice-cream-label task, about 3 minutes), REALM (Rapid Estimate of Adult Literacy in Medicine), and TOFHLA (Test of Functional Health Literacy in Adults). Best practice is a universal precautions approach: assume everyone benefits from plain language, chunk information into 2-3 points at a time, and verify understanding with teach-back ('So I know I explained this well, tell me how you'll take this medicine at home') — never 'Do you understand?', which patients answer 'yes' to avoid embarrassment.

Documentation

Documentation is a legal record. ANCC tests these rules: document subjective data (what the patient says) in quotation marks using the patient's words; document objective data (what you observe and measure) factually. Avoid vague terms ('seems lethargic,' 'appears uncomfortable') — instead write observable facts ('responds only to sternal rub'). Chart timely, in chronological order; if a late entry is necessary, label it 'late entry' with the actual time of the event. Never chart ahead, never chart for another nurse, and never erase or obliterate — correct errors with a single line, initials, and date per policy. If a patient refuses care or medication, document the refusal, your education, the patient's stated understanding, and who was notified.