Discussion: Building Health Histories

Discussion: Building Health Histories

Discussion: Building Health Histories

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.

Photo Credit: Sam Edwards / Caiaimage / Getty Images

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.
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.
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 1 Discussion Rubric

Post by Day 3 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:
Week 1 Discussion

Learning Resources

Required Readings (click to expand/reduce)

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.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history:
Using the past to improve future health. Public Health Reports, (1), 3.

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

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well
as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource
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)

Required Media (click to expand/reduce)

Welcome and General Course Guidelines

Dr. Tara Harris reviews the overall guidelines and the expectations for the course.
Consider how you will manage your time as you review your media and Learning
Resources throughout the course to better prepare for your Discussions, Case
Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and

your Midterm and Final Exams (14m).
Module 1 Introduction

Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the

registration requirements for your use of Shadow Health for your Digital Clinical Experience
(DCE) Assignments as well as the criteria for the DCE Assignments (3m).
Building a Comprehensive Health History – Week 1 (19m)