Building a Health History (Second Response to colleague)

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.


Main Post:

Promoting health and disease prevention for individuals and populations can be done using health risk assessments (Wu and Orlando, 2015).  Patient-centered care is said to be an element of high-quality health care by the Institute of Medicine (Hashim, 2017). By building on discussions and decisions that involve shared information patient-centered care is developed (Hashim, 2017). I chose to use patient-centered questions to interview my patient, who a 55-year-old Asian female is who lives in a high-density public housing complex.

Patients who have a harder time with communication and trusting their physicians such as ethic minorities, have worse health outcomes (Sims, Young, Koopmann-Holm, Jianf, and Tsai, 2018). When the patient feels that their values are considered, they are more likely to listen and adhere to the advice from the physicians (Sims, Young, Koopmann-Holm, Jianf, and Tsai, 2018). One needs to understand the patient to establish a meaningful partnership (Ball, Dains, Flynn, Solomon, and Stewart, 2019). 

Once walking into the room with this patient I would sit down after introducing myself. The first patient-centered question I would ask this patient is, how would you like to be addressed (Ball, Dains, Flynn, Solomon, and Stewart, 2019)? This would show the patient I am taking into consideration how they feel and make sure they know I respect their values. Next I would ask this patient, what would you like for us to do today (Ball, Dains, Flynn, Solomon, and Stewart, 2019)? This would allow for the patient to clearly patient a picture of their expectations of their appointment. I would ask the patient about their living situation and their expectations of their living situations. Do you enjoy this living situation and are you aware of the risk that come along with this living situation are two questions I would asked this patient based of their living situation? Depending on the symptoms this patient presented with, I would ask the patient if they thought that their living situation might be contributing to their symptoms.

During my interview and assessment of this patient I would use courtesy, comfort, connection, and confirmation (Ball, Dains, Flynn, Solomon, and Stewart, 2019). All of these are very important in establishing a relationship with all of our patients. Using patient-centered questions will allow me to personalize question to fit the patient and this will make them feel more comfortable and trusting towards me.



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)