HISTORY COLLECTION FORMAT

BIOGRAPHICAL DATA
 Name
 Age
 Sex
 Marital status
 Hosp. ID No.
 Ward/Bed No.
 Address
 Telephone No.
 Religion
 Education
 Occupation
 Monthly Family Income
 Admission Date
 Discharge Data
 Diagnosis
 Surgery
 Date Of Surgery
 Name Of Dr.

HISTORY OF PATIENT
 Chief complaints
 Hist. Of Present Illness
 Hist. Of Past Illness
 Family History
Name Of Age Sex Education Occupation Relationship Health
Family Status
Member

 Family Tree/ Genogram

 Vocational/ Educational/ Financial History

 Type Of Work
 Type Of Education
 Financial Well Being
 Impact of illness

 Social/ Leisure/ Spiritual/ Cultural History

 Description Of Social Life
 Leisure Interests
 Religious beliefs/ practices
 Impact of illness

 ADL[Activity Of Daily Living]

 Description of daily activity pattern
 Impact of illness

 Health Habits
 Tobacco, Alcohol, Other Drug Use
 Diet/ Description Of Daily Intake
 Mobility And Exercise Pattern
 Sleep Pattern
 Elimination
 Hygienic Practices

 Psychological history
 Stressor/ Self Concept

 Menstrual History
 LMP

 Sexual And Marital History

 General Health
 Occupation
 Relationship
 Staying together
 No. Of Children
 General Health

HEAD TO TOE ASSESSMENT

 General assessment
 Dependency Level
 Completely/partially dependent or independent
 Tubings/ catheters attached

 Physical appearance
 Body Build
 Sensorium And Mental Status
 Bromhidrosis/ Halitosis
 Speech
 Posture
 Gait
 Movement
 Energy Level
 Wt.
 Ht.
 BMI

Vital Signs
 Temp.
 Pulse
 Resp.
 BP
 Pain

Integument
SKIN
 Color
 Vascularity
 Lesions
 Temp.
 Moisture
 Turgor
NAILS
 Shape
 Texture
 Angle
 Color
HAIR AND SCALP
 Skull
 scalp

Head And Neck

 Face
 Lymph Nodes
 Thyroid Gland
 ROM

Eyes
 Eye brows
 Eye lashes
 Eye lids
 Eye balls
 Conjunctiva
 Sclera
 Iris
 Corneas
 Pupil
 PERRLA
 Lens And Fundus
 Muscles
 Vision
Ears
 Ext. ear
 Tympanic membrane
 Hearing

Nose
  Ext. nares
 Nostrils

Mouth And Pharynx

 Lips
 Teeth
 Mucous membranes
 Gums
 Tongue
 Throat And Pharynx

Breast And Axilla

 Shape
 Symmetry
 Skin
 Areola
 Nipple
 Axillary, subclavicular, supraclavicular lymph nodes

Thorax And Lungs

 Ant. Thorax

Cardiovascular And Peripheral Vascular

System
INSPECTION
 Precordium
 Configuration
 Pulsation
 Jugular Veins
 Peripheral Veins
PALPATION
 Carotid Artery
  Pulsations
AUSCULTATION
 Carotid Artery
 Precordium

Abdomen And Gut

 Inspection
 Auscultation
 Percussion
 Palpation

Anus And Rectum

Genito-urinary System
 Inspection
 Palpation

Musculoskeletal System
 Inspection
 Palpation

Neurological System
 Gross Motor And Balance Tests
 Touch Sensation
 Pain Sensation
 Position/ Kinesthetic Sensation
 Mental Status
 Cranial Nerves
 Sensory System
 Reflexes

CASE STUDY
  Introduction
 Definition
 Etiology
In Book In Patient

 Risk Factors
In Book In Patient

 Anatomy/Physiology
 Pathophysiology
 C/F
In Book In Patient

 Diagnostic Evaluation
In Book In Patient
 Radiological
 Laboratory

Investigation Patient’s Value Normal Value Remarks

 Radiological
 Laboratory

 Management
1) Medical
2) Surgical
3) Nursing

Medical management
In Book In Patient
 Pharmacological
 Non – pharmacological

Drug Dose Route Frequency Action Side Nurse’s

Effects Role

Surgical Management
In Book In Patient

Nursing Mangement
 List of nursing diagnoses based on priority needs
 Nursing process
Assessment Nursing Goal Nursing Rationale Implementation Evaluation
Diagnosis Intervention

 Complications
In Book In Patient

 Health Education
 Summary And Discharge Planning
 Bibliography/References