Writer Choice
42068 Please use the references in the learning resources. Thank you.
Discussion: 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 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.
By Day 3
Post a description of the interview and communication techniques you would use with your selected 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.
Required Readings
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
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.
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.
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. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 1, “Medicolegal Principles of Documentation” (pp. 1–14 and abbreviations, pp. 19)
Chapter 2, “The Comprehensive History and Physical Exam” (pp. 23-32)
Note about Uploading Media:
Please refer to the Kaltura Media Uploader page located in the course navigation menu.. The documents on this page provide guidance on how to upload media for your Health Assessment Videos assignments for this course.
Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., L Van Abbema, D. & 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(30), 1–12. doi 10.1186/s12875-015-0241-x. Retrieved from http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0241-x
Wu, R. R. & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: barriers and benefits. Post Grad Medical Journal, 91 (1079), 508–513. doi:10.1136/postgradmedj-2014-133195. Retrieved from http://pmj.bmj.com/content/91/1079/508
Lushniak, B. D. (2015). Surgeon General’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, 130(1), 3–5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245280/
Jardim. T. V., Sousa, A., Povoa, T., Barroso, W., Chinem, B., Jardim, L., Bernardes, R., Coca, A., & Jardim, P. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Family Practice, 15(1111), 1–7. doi 10.1186/s12889-015-2477-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642770/
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