Nr548 Week 4 Study Guide Graded A+

Documentation of History of Present Illness {Ans: should include an opening statement, a characterization of the chief complaint in chronological order, pertinent positive symptoms, pertinent negative symptoms, and other relevant information from the history.}History of Present Illness {Ans: is a concise, clear, and chronological description of the chief complaint which prompted the client's visit. A symptom analysis guided by the mnemonic "OLDCARTS" will reveal information regarding the onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and severity of the symptoms.}family history {Ans: Document information about the client's parents, grandparents, siblings, children, and grandchildren regarding their age, health, and cause of death. Include whether they have conditions such as hypertension, coronary artery disease, stroke, diabetes, or cancer.}Obstetric/Gynecologic {Ans: Document number of pregnancies (gravida), number of deliveries (para-term, preterm, abortions, and living children), menstrual history, methods of contraception, and sexual function.}Surgical {Ans: Document dates, indications, and types of surgical procedures.}Pertinent negatives {Ans: symptoms the client does not have that are expected with a potential diagnosis related to the chief complaint.}History of Present Illness {Ans: How long have you been feeling this way? Did something happen in your life that may have triggered these emotions?