Health Assessment: The General Survey and Subjective Data

Introduction to Health Assessments

This article discusses the health assessment, beginning with the general survey and subjective data.

The General Survey: Make a Judgment Upon Entering the Patient’s Room

The general survey is a snapshot judgment the provider makes about their patient as they first enter the patient’s room. During the general survey, they can determine if the patient is sick. When the provider walks into the room to assess the patient, they should observe or ask:

• How many intravenous (IV) pumps are in the room?
• Is the patient on oxygen? If so, how much? 
• What is the patient’s skin color? Is the color appropriate? Or is it pale or blue?
• How is the patient sitting in bed? Are they smiling as the provider enters the room? Take note of whether the patient is sitting up in the bed or sitting in a chair. Are they able to get up into the chair? A patient that is sitting up in a chair is likely doing better than someone who’s lying in bed.

A general survey of the patient can offer clues to how a patient is doing.

• What does the IV site look like? What IV medications is the patient receiving? Are they receiving any medications? A patient on several IV medications could be sicker than a patient who is not receiving any IV medications.
• Does the patient appear to be in any kind of distress? If the provider walks into a room and the patient is sitting in a tripod position and is breathing heavily, the patient is in distress.
• Look at the patient’s general appearance. Is the patient well-nourished? Does the patient look appropriately their age? Is the patient confused or oriented?

The general survey assessments combine to help the provider determine if the patient is sick.

Related Video – What is the Objective Assessment?

Subjective Assessment

Next is the subjective assessment. The provider must gather the most important information. Sometimes, patients may be quite talkative. However, the provider needs to use their time efficiently to gather the subjective information. In certain cases, they may need to redirect and refocus the conversation.

When asking subjective questions, the provider needs to keep the patient focused. The provider should not be overly concerned that the patient had pneumonia 20 years ago and does not need to hear a 15-minute story about it. That is not relevant to why the patient is currently in the hospital.

The provider must identify the priority and determine where to focus their time and attention. The term focus assessment is frequently used. If the patient presents with cardiac problems, the provider will focus their assessment on the cardiac system. If the patient presents with respiratory problems, the provider will focus the assessment on the respiratory system.

Ask about the Chief Complaint

For example, a patient named Mike presents with a chief complaint of abdominal pain. That is where the provider will focus the subjective assessment. 

When the provider sees Mike, they are going to ask him to go more into detail about the chief complaint. The provider will ask questions to find out the history of present illness.

To gather medical information, ask questions. Keep the questions focused.

Since the patient’s chief complaint is abdominal pain, the provider would use the PQRST method to assess pain. The assessment should start with the chief complaint before moving on to the rest of the subjective data.

The PQRST method to assess pain is:

• P: Provoke
• Q: Quality
• R: Radiates
• S: Severity
• T: Time

The assessment of Mike could go like this:

• Ask Mike about P, which is provoke. Does anything make the pain worse, such as an activity or eating a certain food?
• Then ask about Q, which is quality. Describe the pain. Does it feel dull, sharp, or stabbing? 
• R is for radiating. Does the pain move around anywhere else in the body?
• S is for severity. Ask Mike to rate his pain on a scale from 1 to 10, with 10 being the worst.
• T is for timing. How long has this pain been going on?

The provider needs to ask detailed questions to follow up on the main questions. If the provider enters the patient’s room and asks what provokes the pain, the patient will probably not understand the question. The provider must ask questions using terminology the patient understands.

The following sections outline the rest of the subjective data that the provider needs for their clinical paperwork.

Ask about Medications

Always ask about medications. If the patient takes any medications at home, the provider will have to evaluate whether the medications are appropriate to continue at the hospital.

Read: The Objective Assessment

Ask about Allergies

Ask about allergies. Does the patient have any allergies to food or medications? Have they ever eaten a food or taken a medication and broken out in hives? The patient’s responses need to be documented. The provider also needs to document if the patient has no known allergies.

Ask about Family History

Next is the family history. The most important people to collect information on are the mother, father, and any siblings.

For family history, the medical team typically wants to know about any history of heart disease, hypertension, diabetes, and cancer. The provider may ask something like, “Does your mother have a history of heart disease?” “What about your father?” The provider will also document whether family members are living or not.

For the family history, ask about the patient’s parents and any siblings.

Related Video – Understanding the ACLS Systematic Approach

Complete a Review of Systems

The next part of the subjective assessment is a review of systems. 

Returning to the example above of the patient, Mike, who presented with abdominal pain, the provider would start first with the gastrointestinal (GI) system because that is where the most information is needed. If the provider runs out of time or gets pulled out of the room for any reason, it is most important to gather that information, since that is what he is presenting with.

The provider might ask Mike:

• Have you had any other symptoms along with the abdominal pain?
• Any changes in bowel patterns?
• Nausea or vomiting?
• Any bloody stools, diarrhea, or constipation?
• Changes in appetite?
• Where are you hurting? Is the pain on the side, middle, upper, or lower part of the abdomen?

It is very important, especially with abdominal complaints, that the provider asks about the location of the pain. If the patient is hurting on a certain side of the body, it could be the appendix or the colon. 

The provider will also ask about any abdominal surgeries. If the patient no longer has an appendix, then appendicitis can be ruled out.

Once the provider asks all of the questions about the GI system, the review of systems can continue. The provider will start at the head and work down. The review of systems does not need to be detailed. It needs to address the issues that are most pertinent to the patient’s chief complaint.

A review of the bodily systems helps collect information about the patient’s organ systems. The provider may not have time to cover every organ system.

Starting from the top with the head, eyes, ears, and nose, the provider will ask about the neurology system:

• Any problems with headaches?
• What about any numbness? Tingling?
• Any history of seizures?
• Any eye pain or vision problems?
• Any ringing in the ears?

If the provider asks, “Do you have tinnitus?”, the patient may be confused. Ask them instead if they have ringing in their ears. Providers need to talk in words the patient understands.

Next is the cardiovascular system. Questions for this body system may include:

• Any chest pain?
• Any palpitations where the heart feels like it is beating out of the chest or that it feels like it is beating irregularly?
• Any trouble with your blood pressure?
• Any medication for a heart condition?

Next is the respiratory system. Questions about this body system may include:

• Any shortness of breath currently or in the past?
• Any cough?

If the patient has a cough, the provider should follow up and ask if it is productive or nonproductive and about the appearance of the sputum.

The GI system is next. For the example patient above, this system has already been addressed. However, another important thing to ask, particularly with older patients, is if they have any trouble swallowing. That is important to know if they need to be on aspiration precautions.

Next is the genitourinary system. Questions for this system include:

• Any changes in urination patterns?
• Any difficulty urinating?
• Any pain with urination?
• Any history of urinary tract infections?

Finally, the provider should ask about hematology and endocrinology. For endocrinology, the only question may be about diabetes unless the provider needs to know more. Questions to ask about these systems include:

• Do you find that you bruise easily?
• Do you bleed easily?
• Do you have any history of diabetes?
• Any family history of diabetes?

In women, the provider may want to ask about the thyroid during the review of the endocrine system. Sometimes, women may come in with hypothyroidism.

There are several questions that the provider can ask during the review of systems. Remember that the review needs to keep the patient-focused on the main reason for the visit.

Additional Information

Along with the chief complaint, history of present illness, and review of systems, there are some additional items to collect. One thing to ask is the patient’s code status. Is the patient full code or do not resuscitate (DNR)? Another piece of information to collect is fall precautions. Any fall precautions needs to be documented.

The general survey and subjective data of the health assessment allow the provider to gather important and pertinent information about the patient’s chief complaint as well as their medical and family histories. Knowing why a patient is presenting and if they have any allergies or are taking any medications shape the care the patient will receive.