The Objective Of Building And Documenting A Health History

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The Objective Of Building And Documenting 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. The Objective Of Building And Documenting A Health History

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Building a Health History

This exercise is planned with the objective of building and documenting a health history for a patient. Specifically, the exercise is a critical task of building a comprehensive health history for a 4-year-old African American male residing in a rural community within the United States. From the point of view of a clinician, the focus for creating this health history is to unearth underlying medical aspects and the social determinants of health that significantly influence well-being of the patient. Given this, applying age-appropriate communication techniques and making use of relevant risk assessment instruments are necessary in aiding the developing an accurate health history. The Objective Of Building And Documenting A Health History

 Interview Summary and Communication Techniques

The interview planned for this exercise is with a 4-year-old child and it will be necessary for creative strategies to be applied in recognition of the minor age that the child falls under. Citing Sheldrick et al. (2020), it will be necessary that the exercise be done between the child and the clinician but in the presence of the parent or a caregiver to help intervene or clarify some issues. The first step I would need to take in this exercise is establishing rapport and an ideal way of doing this is through friendly introductions. The use of age-appropriate language is vital at this point to help place a level playing field between the two of us. The interview would take the form of open-ended questions directed to the caregiver through which I would explore the medical history of the child and paying particular attention to any pre-existing conditions. Focusing on the child, I would incorporate play-based communication methods for example interactive games like drawing while still engaging in conversations with them. According to Sullivan (2018)The Objective Of Building And Documenting A Health History, the use of a proactive strategy guarantees the development of a thorough health history while at the same time upholding a comfortable experience for the child during interview.

Rationale for Using These Techniques

The selection of these techniques is justified by the fact that they are age-appropriate communication strategies which are vital when interacting with a 4-year-old. For example, the use of open-ended questions motivates the child to freely express themselves which is necessary in providing insights into their health history. Secondly, the use of play therapy is necessary in helping the child be in an environment they are familiar with. The benefit this has as explained by Ball et al. (2021) is promoting trust. For the caregiver or parent present in an interview, the environment helps ease potential anxiety associated with medical discussions. For the participating parent or caregiver, the use of visual aids is important in enhancing understanding especially in areas like immunizations and dietary habits.

 Appropriate Risk Assessment Instruments

There are a handful of risk assessment instruments that could be used in this particular case. The first one is the Ages and Stages Questionnaires (ASQ) and the second one is the Pediatric Symptom Checklist (PSC) are suitable choices (Sheldrick et al., 2020). The ASQ is a risk assessment tool that looks into the developmental milestones of a child which is important in aiding the identification of potential delays or concerns. According to Sullivan (2018)The Objective Of Building And Documenting A Health History, this assessment aligns with the need to evaluate age-specific developmental markers. On the other hand, the PSC identifies the emotional and behavioral issues of a child. In this particular case, the instrument would consider the psychosocial context of the child. Reflecting on these two instruments, they are both culturally sensitive and are validated for diverse populations. More importantly, making use of these two guarantees a comprehensive assessment of developmental and behavioral aspects. This has the benefit of facilitating early detection of potential risks.

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Targeted Questions

  1. Please tell me about some of the things your child is able to do independently
  2. Has the child had any significant illnesses since birth?”
  • Please describe a typical day of meals for the child. In this, please include his main preferences and notable aversions.
  1. Are there specific safety measures implemented in the house to safeguard the well-being of the child?”
  2. What is the child’s sleep routine? Do they have observable bedtime habits or difficulties falling asleep? The Objective Of Building And Documenting A Health History

Before coming up with the targeted questions for the caregivers or parents majorly, and to a lesser extent the child in question, I would ensure that they are aligned with the context of the patient. Commenting on this, Ball et al. (2021) advised that taking this approach is necessary as it helps address the prevailing social determinants of health. An ideal example would be asking the child, “Who do you live with and who attends to you when you feel unwell?”, or to the parent, “How often does your child visit the doctor?”. The benefit with this nature of question is that they help probe the access to healthcare for the child and in identifying potential barriers to healthcare access.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.

Sheldrick, R. C., Marakovitz, S., Garfinkel, D., Carter, A. S., & Perrin, E. C. (2020). Comparative accuracy of developmental screening questionnaires. JAMA pediatrics, 174(4), 366-374. 10.1001/jamapediatrics.2019.6000 The Objective Of Building And Documenting A Health History

Sullivan, D. D. (2018). Guide to clinical documentation. FA Davis.

NURS 6512N WEEK ONE DISCUSSION INSTRUCTIONS

TOPIC: 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.

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. The Objective Of Building And Documenting A Health History

Here is your assigned patient for Week 1. You will only have one to address in the discussion board.

  1. 4 year old African American male living in a rural community

 To prepare:

With the information presented in Chapter 2 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 oneof the risk assessment instruments presented in Chapter 2 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 fivetargeted questions you would ask your selected patient to assess his or her health risks and begin building a health history. The Objective Of Building And Documenting 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.

REQUIRED READING:

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach(10th ed.). St. Louis, MO: Elsevier Mosby.
    • Chapter 2, “The History and Interviewing Proce
      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 unitLinks to an external site.. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0
  • Chow, 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 EDLinks to an external site.. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015
  • Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced levelLinks to an external site.. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238 The Objective Of Building And Documenting A Health History

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Shadow Health Support and Orientation Resources

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

  • Shadow Health. (2021). Welcome to your introduction to Shadow HealthLinks to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
  • Shadow Health. (n.d.). Shadow Health help deskLinks to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
  • Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students.
  • Document: Shadow Health Nursing Documentation TutorialDownload Shadow Health Nursing Documentation Tutorial(Word document) The Objective Of Building And Documenting A Health History