[The "health history" of patients or groups as a method of recording data]

This paper describes the "health history", a method for obtaining data on patients, families and groups developed by the Nursing Department of Valle University, in Cali, Colombia. According to the authors, the method can be used by all health professionals and serve as a basis for nurse training. It discusses the obstacles that have arisen with the application of different concepts in nursing instruction and the difficulties that are sometimes caused when the nurse is insufficiently trained. It also dwells on the need for coordination between teaching and service institutions. The paper gives the sequence of steps to be followed in compiling the health history, as follows: collection of the information, statement of the problems, diagnosis, the plan to be followed, and progress and observation of the patient. Specimen health histories, one for an individual and family and the other for a group, are included to illustrate the theoretical aspects. To promote the use of the health history by the entire health team it is recommended that collective learning exercises be conducted to help define the roles of its different members.