Building a Health History

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. Building a Health History

For this Discussion, you will take on the role  of a clinician who is building a health history for a particular new  patient assigned by your Instructor.

                                               To prepare:

By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. (new patient profile):  14-year-old biracial male living with his grandmother in a high-density public housing complex 

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 social determinants of health? Building a Health History

What  risk assessment instruments would be appropriate to use with each  patient, or what questions would you ask each patient to assess his or  her health risks?

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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 5 of the Seidel’s Guide to Physical Examination 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. Building a Health History

Post a summary of the interview and a  description of the communication techniques you would use with your  assigned patient. Explain why you would use these techniques. Identify  the risk assessment instrument you selected, and justify why it would be  applicable to the selected patient. Provide at least five targeted  questions you would ask the patient.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

· Chapter 1, “The History and Interviewing Process”

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. Building a Health History

· Chapter 5, “Recording Information”

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. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

· Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241-x

Note: You will access this article from the Walden Library databases.

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edsgea&AN=edsgcl.429265076&site=eds-live&scope=site  Building a Health History

Note: You will access this article from the Walden Library databases.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edsgea&AN=edsgcl.426834285&site=eds-live&scope=site

Note: You will access this article from the Walden Library databases.

Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8   Building a Health History

Note: You will access this article from the Walden Library databases.

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us Building a Health History

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