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 a particular new patient assigned by your Instructor.

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To prepare:

With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
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?
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?
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.

By Day 3 of Week 1

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.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

The objectives of building a patient history are to establish the primary concern that prompted the patient to seek care, establish the patient’s expectations from the encounter, and express interest in the patient’s concerns to form a partnership for care (Ball et al., 2019). Building a complete health history can help prevent harm to the patient, expose chronic illnesses, identify risk factors, and reveal potential differential diagnoses (Nichol et al., 2020). When deciding what questions to ask and how to ask them, the provider must consider the patient’s age, gender/gender identity, disabilities, cultural preferences, and social determinants of health (SDOH). The provider also needs to be aware of their own prejudices and attitudes, being careful not to become a barrier to effective communication (Ball et al., 2019).

To target questions related to SDOH, the provider should consider the Social Needs Screening Tool. The tool will provide insight into what immediate needs the patient has and which SDOH are affecting the patient’s health. It is not only important to identify needs but also to have a plan to deal with them. Essential questions include housing security, food security, employment security, and personal safety (American Academy of Family Physicians, 2019).

The patient under consideration for this discussion is a 76-year-old black male with disabilities living in an urban setting. The African American population is the least healthy and poorest ethnic group in the United States. Potential health risks for this patient based on his SDOH include increased risk of heart disease and stroke due to high blood pressure, high cholesterol, smoking, physical inactivity, and obesity (Noonan, Velasco-Mondragon, & Wagner, 2016). Additionally, this patient is at increased risk of injury, development of chronic disease, poverty, social isolation and exclusion, mental health disorders, and elder abuse (World Health Organization, n.d.). The patient’s male gender is also a risk factor. Black men are the least healthy group in the United States. Black men die at a younger age than all other ethnicities except for Native Americans (Gilbert et al., 2016).

One of the risk assessment tools that could be used to assess this patient is the Missouri Alliance for Home Care (MAHC)-10. The MAHC-10 is a series of ten questions assessing age, number of diagnoses, fall history, the existence of incontinence, visual and functional impairment, environmental hazards, polypharmacy, pain, and cognitive impairment. A score of four or higher indicates an increased risk for falls. The tool is used to assess fall risk in patients over 60 years old who live independently (Calys, Gagnon, & Jernigan, 2012).

Five questions to begin the health history assessment for this patient are:

How would you like to be addressed?
Where do you live, and who lives with you?
How did you get to the clinic today?
What concern brings you to the clinic today? How do you feel about your health?
What types of treatments would you like to pursue?

References

American Academy of Family Physicians. (2019). Social determinants of health Guide to social needs screening. aafp.org. Retrieved August 31, 2021, from https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-guide-sdoh.pdf

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.). Mosby.

Calys, M., Gagnon, K., & Jernigan, S. (2012). A validation study of the Missouri alliance for home care fall risk assessment tool. Home Health Care Management & Practice, 25(2), 39–44. https://doi.org/10.1177/1084822312457942

Gilbert, K. L., Ray, R., Siddiqi, A., Shetty, S., Baker, E. A., Elder, K., & Griffith, D. M. (2016). Visible and invisible trends in black men’s health: Pitfalls and promises for addressing racial, ethnic, and gender inequities in health. Annual Review of Public Health, 37(1), 295–311. https://doi.org/10.1146/annurev-publhealth-032315-021556

Nichol, J. R., Sundjaja, J. H., & Nelson, G. (2020, September 7). Medical history. NCBI-StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK534249/

Noonan, A. S., Velasco-Mondragon, H. E., & Wagner, F. A. (2016). Improving the health of African Americans in the USA: An overdue opportunity for social justice. Public Health Reviews, 37(1). https://doi.org/10.1186/s40985-016-0025-4

World Health Organization. (n.d.). Risk factors of ill health among older people. Retrieved September 1, 2021, from https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/data-and-statistics/risk-factors-of-ill-health-among-older-people

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.

I agree with your assertions regarding the importance of building a patient’s health history. Essentially, the health history profile can help in the identification reason for seeking care and aid in the establishment of a proper and effective treatment plan (Ball, Dains, Solomon, & Stewart, Elsevier Health Sciences.). In addition to the elements of age, gender, social determinants, and culture preference, the development of a reliable history also relies on the ability of the healthcare professional to gather and accurately interpret the information from the patient. Besides, the healthcare professional should lay down a proper plan to ensure that the questions during the information collection process are well structured for reliable feedback from the patient.

In addition to the screening tool of the interview questions and the selection of the risk assessment technique, I would also suggest the consideration of communication techniques that should be used by the interviewer when building the patient’s health history. Ideally, a proper framework of communication plays an essential role in ensuring that the patient is comfortable with the interview setting and all the questions are answered with complete transparency (Noll, Ginsberg, Elahi, & Cavalieri, 2016). As such, one of the communication techniques that should be implemented when building the patient’s history is the use of open-ended questions. With such a structure, the patients will provide more information that can help in building a reliable profile. Active listening is another communication technique that should be implemented when building a patient history (Tan, Zhou, & Kelly, 2017). The healthcare professional should not only be able to listen but also be able to interpret the collected information. As such, efficient communication enables the proper choice of risk assessment that can help in building a usable patient history.

References

Ball, J. W., Dains, J. E., Solomon, B. S., & Stewart, R. W. ( Elsevier Health Sciences.). Seidel’s Guide to Physical Examination. 2015.

Noll, D. R., Ginsberg, T., Elahi, A., & Cavalieri, T. A. (2016). Effective patient-physician communication based on osteopathic philosophy in caring for elderly patients. Journal of Osteopathic Medicine, 116(1), 42-47.

Tan, T. C., Zhou, H., & Kelly, M. (2017). Nurse–physician communication–An integrated review. Journal of Clinical Nursing, 26(23-24), 3974-3989.

response 2

Hi xxx, thank you for your post. As stated in the discussion, “building a complete health history can help prevent harm to the patient, expose chronic illnesses, identify risk factors, and reveal potential differential diagnosis (Nichol et al., 2020). I appreciate this perspective because it includes patient safety. I believe that the most critical aspect of my career is keeping patients as safe as possible. I found your post, as well as others in our class, to be educational and rewarding. Just like in the field, there are always opportunities to learn. I may know something that someone else does not and vise versa. I do my best to stay open and learn as much as possible. For example, the communication techniques you mentioned could distinguish between obtaining information from a patient critical to their care and missing opportunities. Breast cancer is the most common form of cancer amongst women globally (Ferlay et al., 2013). From my experience, many women have annual checks to rule out breast cancer. As a provider, I will create safe environments for sharing as more than one factor makes women more susceptible than others. One of those factors may be genetic factors passed from mother to daughter (Chatterjee,2006). A patient sharing their mother’s experience with cancer may help in diagnosing more effectively. Obtaining a patient’s history as well as family history can assist in the rule out of disease.

Keep up the great work, Sarah; it is a lifelong process. Have a great quarter!

Chatterjee A, Mambo E, Sidransky D. Mitochondrial DNA mutations in human cancer. Oncogene. 2006;25(34):4663–4674

Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Globocan 2012 v1.0. Cancer Incidence and Mortality Worldwide. IARC Cancer Base No. 11 [Internet] Lyon, France: International Agency for Research on Cancer; 2013.

Nichol, J. R., Sundjaja, J. H., & Nelson, G. (2020, September 7). Medical history. NCBI-StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK534249/