Categories and Influencing Factors

Categories

Categories of the complete subjective health assessment (as illustrated in Figure 1.4) vary depending on the framework you follow, but generally include:

  • Introductory information: Demographic and biographic data.
  • Main health needs (reasons for seeking care).
  • Current and past health.
  • Mental health and mental illnesses.
  • Functional health.
  • Preventive treatments and examinations.
  • Family health.
  • Cultural health.
Computer with the categories of the complete subjective health assessment on the screen.
Figure 1.4: Categories of the Subjective Health Assessment

You begin the assessment with an introduction followed by collecting information about demographic and biographic data and then, main health needs. Afterwards, there is no specific order in which these categories must be assessed. Often it depends on the client’s main health needs or reasons for seeking care. Sometimes it depends on the natural flow of conversation that occurs with the client. Usually, you assess sections that involve sensitive questions as well as cultural health towards the end when you have had the opportunity to develop a level of trust with the client. Remember, when introducing yourself state your full name, designation, and pronouns, and then ask the client what name and pronouns you should use to refer to them. It is important not to use the term “preference” when referring to pronouns and gender as these are not preferences.

In addition to these categories, you may incorporate subjective questions specific to each of the body’s systems; this phase is called a Review of the Systems. These questions give you insight into each body system (e.g., skin, eyes, cardiovascular, musculoskeletal). Depending on the client’s response and the reporting of cues that prompt your concern, you may probe further with more specific questions. In other readings, you will learn about subjective questions related to each body system.

Clinical Tip

Always ask one question at a time.

Influencing Factors

Influencing factors constitute common situational issues that can arise during a subjective data assessment. Always consider factors that may influence how you ask questions and the validity and reliability of the subjective data collected. These situational factors can be difficult to both assess and address in certain cases (see Table 1.2).

Factors Strategies
 

Clients may be hyperaware of the situation and wonder why you are asking certain questions.

 
  • Begin by sharing with the client why you are asking these types of questions.
  • Encourage the client to ask you questions if they are uncertain about why certain information is being sought.
  • Normalize sensitive questions by stating: “I ask all clients about X so that I can better understand the context of their health and illness.”
 

Clients may downplay or exaggerate what they tell you.

 
  • Seek clarification.
  • Reframe the questions you ask.
  • Paraphrase what the client says and ask if you have captured their meaning correctly.
 

Clients may withhold information because they fear sharing information, feel judged by sharing certain information, and/or have a condition that is often stigmatized.

 
  • Emphasize confidentiality.
  • Introduce sensitive questions later in the interview once you have established a therapeutic and trusting relationship.
 

Clients may not be fully conscious or oriented due to a physical injury, a mental health condition, a traumatic event, or substance use.
  • It is important to be patient and give clients time to think and respond to your questions.
  • You may need to delay asking some questions until the client begins recovering.
  • If appropriate, ask other people who can share information about the client to corroborate it.

Note: With a client who is under the influence of a substance, it is important to avoid prejudice, remain nonjudgmental, treat them with respect, speak slowly and clearly with simple language, provide a safe environment for them, and continue to monitor while observing changes in behaviour and level of consciousness.
 

Clients may function at a developmental age (as opposed to actual age). Developmental age is the age that a client functions at on a cognitive, physical, emotional, and social level. You need to consider this factor with all ages across the lifespan.

 
  • Tailor your language and tone of voice to the client’s developmental age.
  • Always use a respectful and professional tone.
  • Create space for others to be involved and/or invite a care partner to be present.

Table 1.2: Influencing factors and strategies

 

Points of Consideration

It is important to document who provides the subjective data. Usually, subjective data is provided by the client (primary source), but in some situations it may be collected from the client’s chart, family members, friends, co-workers, care partners, or interpreters
(secondary sources). In certain cases, the client may be unable to speak or share information, or may speak a different language than you, or be unconscious. Additionally, a care partner (such as a family member) may need to provide subjective data for a newborn or a client with developmental, cognitive, or mental health states that prohibit them from speaking.

Test Yourself

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The Complete Subjective Health Assessment Copyright © 2019 by Jennifer Lapum; Oona St-Amant; Michelle Hughes; Paul Petrie; Sherry Morrell; and Sita Mistry is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License, except where otherwise noted.

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