Posted: February 1st, 2021
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
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
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.
Chapter 2, “History Taking and the Medical Record” (pp. 15–33)
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.
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
16-year-old white pregnant female living in an inner-city neighborhood
The interview process has to be adjusted pending on the age group, gender, financial status, culture, and language barrier of the individual being assessed. One must provide a private area and be close to the patient during the interview to provide comfort. Use of laymen’s terms helps the individual to understand healthcare information clearly. Making eye contact is especially important unless there is a cultural factor involved. Taking notes should be minimal and if using a computer; it should be positioned so the patient can see the screen as well. Introduce one’s self to the patient and others present and use their names to build a friendly trustworthy environment.
reluctant to talk and have a clear need for confidentiality (Stewart, 2019).
When speaking with my adolescent patient I would emphasize that our discussion is confidential with limitations if there is a danger to her or others. We will speak privately unless she wants someone else present. She will be given the opportunity to discuss whatever topics she feels comfortable discussing.
There are several areas to concentrate on to build a history based on social determinants of health. One should enquire about the individual’s personal status, sexual history, living conditions, occupation, environment, military record, and social needs.
According to the information provided my patient lives in an inner city neighborhood. This may be an indication of poverty and limited resources. One would inquire if housing, clothing, food, and access to medical care are adequate. If they are not, community resource information would be provided and a social worker referral to aide her. Also, one must ascertain if she is in an abusive relationship or being abused at home.
Assessing an individual’s health risks is very important in determining what potential health problems one may face. “One of the main goals of documenting the social history (SH) of the patient is to identify factors outside of past or current medical conditions that may influence the patient’s overall health or behaviors that create risk factors for specific conditions” (Sullivan, 2018). Asking what their eating habits are, do they exercise, how much alcohol do they consume, do they smoke cigarettes, do they use recreational drugs, what are their sleeping habits, do they take their medications as prescribed, do they practice unsafe sex, and what is their family history of medical problems. Also, inquiring about their family history of mental illness is important. Religion and culture can affect how the individual’s treatment plan will be developed.
One would obtain the young lady’s family health history at this time to determine if she is at risk for familial issues during her pregnancy. This would be a great opportunity to provide prenatal education and stress the importance of continuity of care during pregnancy.
Adolescent girls are more likely to die during childbirth than women in their twenties or older. If a pregnancy is unplanned, the mother may not be getting the prenatal care she and her baby need or may not even be healthy enough to carry a child to term.
Heuristic. (2016). Risks of Teen Pregnancy. Retrieved from: (nationwidechildrens.org)
Stewart, B.S.J.B.J.F.J.D. R. (2019) Seidel’s Guide to Physical Examination. [VitalSource
Bookshelf]. Retrieved from https://bookshelf.vitalsource.com/#/books/9780323481953/
Sullivan, D. D. (2018). Guide to Clinical Documentation. [VitalSource Bookshelf]. Retrieved
Photo Credit: Getty Images/Caiaimage
Place an order in 3 easy steps. Takes less than 5 mins.