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
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
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.
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.
- 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.
Respond to this post. At least 2 citations. APA format. 7th edition
Building a Health History
My assigned patient for this week’s discussion is a 14-year old biracial male living with his grandmother in a high-density public housing complex. As clinicians, it is very important to gather as much pertinent information as you possible can. This will help with building health history and identify potential issues or concerns. Building health history and gathering pertinent information also give clinicians the opportunity to customize care to a patient’s individual needs. This will also help with forming diagnosis and implementing plan of care.
Interview and Communication Techniques
When conducting an interview with an adolescent, it is imperative that you develop a rapport with the patient, parents, or guardian. Developing a rapport will make the adolescent comfortable and easier to communicate with. I would provide privacy so that the patient and I are away from his family. This will allow the patient to share information with me that he may not disclose if his family was present. I would first find out about his interests, hobbies, and other things he enjoys doing. I would inform him that the environment is a safe space, and he should express himself as he sees fit. I would then begin my head to toe assessment, informing the patient of what I am doing while doing it. While doing my head to toe assessment, I would allow the teen to talk about any concerns he may currently have. I would also use the opportunity to enquire about school, nutrition, health, activities with friends and his homelife. After completing my assessment, I would invite his guardian to rejoin us and give her the opportunity to express any concerns or issues she may have. I would advocate for my patient as I see fit and I would educate all parties involved on any abnormal findings and the best plan of care. When communicating, I would use simple words that are easily understood, to prevent any miscommunication or misunderstanding.
Risk Assessment Instrument
I chose the HEADSS interview tool for my adolescent patient. This is a screening tool that is used to facilitate communication and to create a sympathetic, confidential, and respectful environment where youths may be able to attain adequate healthcare (BC Children’s Hospital, n.d.).
Home: Who lives with the adolescent? Does he have roommates? What are the relationships like with the other persons living in his household?
Education and Employment: Which school is he attending? How are his grades? What is his favorite subject? Does he like going to school? How is his relationship with his teachers and classmates? What are his future goals?
Activities: Sports activities, hobbies, favorite music/movies, and exercise regimen.
Drugs: Any tobacco use, illicit drug, or alcohol use?
Sexuality: Sexual orientation, any physical or sexual abuse, ask if patient is sexually active, knowledge of STD, and use of condoms.
Suicide/Depression: Enquire about suicidal or homicidal ideation (past or present), mood swings, emotional outburst, and feelings of depression.
Substance abuse is an identified risk factor among adolescents. According to the World Health Organization (2018), harmful drinking among adolescents is a major concern because it is an underlying cause of injuries, violence and premature deaths.
Five Targeted Questions
My five target questions are:
• Have you ever had any thoughts of harming yourself or anybody else?
• Are you sexually active and if so, are you using condoms?
• Have you ever used alcohol, or illicit drugs?
• Do you feel comfortable at home or at school?
• Tell me about how you feel at home. Are you comfortable, do you think you are being treated
BC Children’s Hospital (n.d.). H.E.A.D.S.S.- A Psychosocial Interview for Adolescents.
World Health Organization (2018). Adolescents: health risks and solutions.
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