Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following new patients:

·          76-year-old Black/African-American male with disabilities living in an urban setting

·          Adolescent Hispanic/Latino boy living in a middle-class suburb

·          55-year-old Asian female living in a high-density poverty housing complex

·          Pre-school aged white female living in a rural community

·          16-year-old white pregnant teenager living in an inner-city neighborhood

To prepare:

With the information presented in Chapter 1 in mind, consider the following:

·          How would your communication and interview techniques for building a health history differ with each patient?

·          How might you target your questions for building a health history based on the patient’s age, gender, ethnicity, or environment?

·          What risk assessment instruments would be appropriate to use with each patient?

·          What questions would you ask each patient to assess his or her health risks?

·          Select  one  patient from the list above on which to focus for this Discussion.

·          Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.

·          Select  one  of the risk assessment instruments presented in Chapter 1 or Chapter 26 of the course text, or another tool with which you are familiar, related to your selected patient.

·          Develop  at least five  targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

Questions to be addressed in my paper:

1.      A description of the interview and communication techniques you would use with your selected patient.

2.      Explain why you would use these techniques.

3.       Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient.

4.      Provide at least five targeted questions you would ask the patient.

5.      Summary with Conclusion

 

REMINDERS:

1)        2-3 pages (addressing the 5 questions above excluding the title page and reference page).

2)        Kindly follow APA format for the citation and references! References should be between the period of 2011 and 2016. Please utilize the references at least three below as much as possible and the rest from yours.

3)       Make headings for each question.

 

References: Readings

·          Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).  Seidel’s guide to physical examination  (8th ed.). St. Louis, MO: Elsevier Mosby.

o     Chapter 1, “The History and Interviewing Process” (pp. 1–21)

This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

o     Chapter 26, “Recording Information” (pp. 616–631)

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

·          Sullivan, D. D. (2012).  Guide to clinical documentation  (2nd ed.). Philadelphia, PA: F. A. Davis.

o     Chapter 1, “Medicolegal Principles of Documentation” (pp. 1–12 and abbreviations, pp. 18)

o     Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–36)

·          Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). The effects of gender and age on health related behaviors.  BMC Public Health,  9, 213–220.

Retrieved from the Walden Library databases.

This article describes a study that sought to determine the effects of gender and age on health-related behaviors. In the study, the authors also investigated the effects of screening practices, health beliefs, and perceived future health needs.

·          Delpierre, C., Lauwers-Cances, V., Datta, G. D., Berkman, L., & Lang, T. (2009). Impact of social position on the effect of cardiovascular risk factors on self-rated health.  American Journal of Public Health,  99(7), 1278–1284.

Retrieved from the Walden Library databases.

This study assessed the influence of education level on the association between self-rated health and cardiovascular risk factors. The authors explain their methods and results, and they provide recommendations for similar studies in different countries and cultures.

·          Lee, D. W., Neumann, P. J., & Rizzo, J. A. (2010). Understanding the medical and nonmedical value of diagnostic testing.  Value in Health,  13(2), 310–314. 

Retrieved from the Walden Library databases.

The authors of this article detail their attempts to develop a framework for defining the potential value of diagnostic testing. The authors also discuss the implications of their framework for health care delivery systems.

·          University of Michigan Medical School. (2003).  Geriatric functional assessment. 

Retrieved from  http://www.med.umich.edu/lrc/coursepages/m1/HGD/GeriatricFunctionalAssess.pdf

This article provides an exercise that emphasizes accurate functional status assessments and effective communication with older patients. The authors recommend tools and techniques to be used when caring for older patients.

Optional Resources

·          LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).  DeGowin’s diagnostic examination  (9th ed.). New York, NY: McGraw- Hill Medical.

o     Chapter 2, “History Taking and the Medical Record” (pp. 15–33)