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:
Assigned patient: 40-year-old black recent immigrant from Africa without health insurance.
With the information presented in Chapter 1 of Ball et al. 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 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.

Resources:

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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.
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

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. For more information on Building a Health History checkout this: https://en.wikipedia.org/wiki/Health

Building a Health History

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