Exam 4: The Complete Health History and Mental Status Assessment

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Although the form itself may vary among health care settings, the following information is usually obtained: biographic data, source of history, reason for seeking care, current health or history of current illness, past health, family history, review of systems, and functional assessment, including activities of daily living (ADLs). It should be noted that in the past the reason for seeking care was referred to as the chief complaint, and this term may still be noted when one is reading health histories written by other health care providers.

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Consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions all need to be considered when one is assessing mental status. For some aspects of the assessment, direct questions, such as "Where are you?" may need to be asked, whereas for others the examiner can gather the data indirectly through the way in which the patient responds to questions asked during the health assessment.

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As can be seen, the health history provides the basis for decisions regarding the health and wellness care needs of each patient. To ensure the completeness of data collected, eight characteristics that should be addressed for each symptom identified. These characteristics are location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient's perception of the symptom. For each body system assessed for symptoms, health-promoting behaviors are also assessed. The student might find it helpful to organize the symptom analysis into the mnemonic PQRSTU (provocative or palliative, quality or quantity, region or radiation, severity scale, timing, and understanding patient's perception of the problem).