First Response on a post.(BUILDING A HEALTH HISTORY)

PLEASE RESPOND TO THE MAIN POST OF MY COLLEAGUE.You don’t have to argue with her post.You may give suggestions on how to interview or how you are going to build health history of the patient (case study )that was presented below.

 

Case study: 76-year-old black male with disabilities living in an urban setting.

 

 

When you are interviewing individuals to gather data to build health history communication techniques will vary because you must take into account the age, knowledge level, health literacy, cultural and social factors as well as the rapport between patient and provider which will help you to gather the needed data. Health literacy is the degree to which an individual can obtain, process, and understand basic health information and the services needed to make appropriate health decisions (Koduah, Leung, Leung, & Liu, 2019). The way one communicates using the appropriate verbal communication techniques as well as non-verbal cues/gestures and active listening will help to ensure the necessary data elements to build the health history can be obtained.  SDH data can be collected through a variety of mechanisms, though they can operationally be distinguished as either collected for individual- or community-level purposes (Wallace, Decosimo, & Simon, 2019). The social determinants of health focus on economic and social conditions that influence differences in the health status of individuals and groups so questions should be written to address but not in a confrontational or overbearing manner these differences in an attempt to gain the appropriate data for the different groups.

The communication technique used for this 76 year old client was motivational interviewing. One approach many experts encourage physicians to use is motivational interviewing (MI), a series of techniques to get at the root of patient concerns and help encourage them to make healthy behavior changes; the involved skills are open ended questions, affirmations, reflective statements and summary (OARS) (Shute, 2019).  The goal is to gain trust, gather health information and make sure understanding is mutual between patient and physician. This type of interviewing allows the patient to openly discuss issues but at the same time receive assurance that what is happening to them has and can happen to other people so they are not alone.

In our text, several risk assessment tools were mentioned that focus on adults as well as children and adolescents and the appropriate tool must be used to ensure that one gathers the correct information to build a complete and comprehensive profile. For this patient with a disability, the goal is to ascertain functional level so a functional screen would be conducted. A functional assessment is an attempt to understand the patient’s ability to achieve the basic activities of daily living and this assessment should be made for all older adults and for any person limited by disease or disability, acute or chronic (Ball, Dains, Flynn, Solomon, & Stewart, 2019).

Obtaining the health information or history from a patient requires asking the correct questions. So many questions come to mind for this specific case but I would use a mixture of open ended questions and yes or no questions to see if can gather some information about the patient.

Targeted Questions:

1.      What brings you in today?

2.      What other medical problems have you been diagnosed with?

3.      Are you taking any medications?

4.      How long have you had your disability?

5.      Are you troubled by financial questions about medical care or insurance coverage?

 

 

RESOURCES: (Please use one of the resources below on top of the other resources you may use for the references).

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)

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