A nurse on a mental health unit is collecting data from a newly admitted client. Which of the following information should the nurse document as part of the client's medical history?
Explanation & Rationale
A. Consumes foods with purines: Dietary habits may be relevant for certain conditions, such as gout, but consumption of purine-rich foods is not part of the client’s medical history. It is considered current lifestyle information rather than past or ongoing medical diagnoses. B. Hospitalized for bipolar disorder 2 years ago: Previous hospitalizations for psychiatric conditions are a key component of the client’s medical history. This information provides context for current mental health status, risk assessment, and planning of care, and helps identify patterns in symptom management and treatment response. C. Step-sister has major depressive disorder: Family history is important and documented separately under genetic or familial risk factors. While it informs potential predisposition, it does not constitute the client’s personal medical history. D. Plans to start group therapy sessions once per week: Future intentions or planned interventions reflect care planning and goals rather than historical medical data. This information is documented in the plan of care rather than the medical history section.