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.Photo Credit: Sam Edwards / Caiaimage / Getty ImagesTo 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.Below is the discussion————————–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.BELOW IS THE RESOURCES / REQUIRED READING————————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)Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279-1287. https://doi.org/10.1007/s40520-019-01309-0Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457-460. https://doi.org/10.1016/j.ajem.2018.06.015Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238-243. https://doi.org/10.12968/bjon.2021.30.4.238.please don’t forget to add 5 references not more than 5 years old. Please make sure to go through the rubic.BELOW IS THE CASE STUDY AND ASSIGNED PATIENT————————21-year-old Filipino college student living in a dorm wanting to know what birth control :please make sure to use headings to answer all the questions and please use headings to point part of the question you are answering CORE SKILL: tailoring the interview to the specific patient in front of you. The graded object is not a generic history template but a set of TARGETED questions with a stated rationale for each.
THE COMMUNICATION TOOLKIT — name your techniques explicitly:
— Open-ended → focused → closed funnel structure.
— MOTIVATIONAL INTERVIEWING (OARS: open questions, affirmations, reflective listening, summarizing) — especially for behavior-change topics where confrontation produces resistance.
— NORMALIZING/UBIQUITY technique before sensitive questions (“I ask everyone about…”) — this reduces shame and improves disclosure.
— TEACH-BACK to verify comprehension (and note: teach-back checks YOUR communication, not the patient’s intelligence — phrase it that way: “I want to make sure I explained that clearly”).
— Trained MEDICAL INTERPRETERS, never family members and never children.
— RISK ASSESSMENT INSTRUMENTS by population — and cite them by name: PHQ-9 (depression), GAD-7, AUDIT-C or CAGE (alcohol), CRAFFT (adolescent substance use), Edinburgh Postnatal Depression Scale, HEEADSSS (adolescent psychosocial: Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety), Mini-Cog or MMSE (cognition in older adults), Morse or Timed Up and Go (falls), Braden (pressure injury), and validated intimate partner violence screens (HITS, HARK).
FOR THE ADOLESCENT PATIENT (e.g., the 16-year-old pregnant patient in the prompt): CONFIDENTIALITY IS THE CENTRAL ISSUE. Interview the adolescent ALONE for part of the visit — say so explicitly, because a history taken in front of a parent is not a history. Explain confidentiality AND its limits (harm to self or others, abuse) at the START, not after a disclosure. Know that minors have statutory rights to confidential care for pregnancy, contraception, STIs, and often mental health and substance use — BUT THIS VARIES BY STATE, and naming your state’s actual rule is what earns credit. Use HEEADSSS. Assess for coercion and reportable abuse (a 16-year-old’s pregnancy raises the question of the partner’s age and statutory issues — a mandated-reporter consideration that a strong answer names without moralizing). Screen for intimate partner violence (pregnancy is a period of elevated risk). Address social determinants: housing, food security, school continuation, transportation, insurance, and social support — for an inner-city adolescent these are not background details, they are the clinical picture.
THE FIVE P’s for a sexual history: Partners, Practices, Protection, Past history of STIs, Prevention of pregnancy. Ask about behavior, not identity.
SOCIAL DETERMINANTS SCREENING is a graded element in most versions of this rubric: economic stability, education, healthcare access, neighborhood/built environment, social context. Use a validated tool (PRAPARE, or the AHC HRSN screening tool).
BUILD 5 TARGETED QUESTIONS and give each a RATIONALE tied to a risk you are trying to identify or exclude. A question without a stated rationale earns nothing.

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