Comprehensive Health History Taking

Comprehensive Health History Taking
An abstract is required.
Select one patient (neighbor, family, or friend) and write-up their comprehensive health
history. Include the following variables:

  1. Identifying data.
  2. Past medical history.
  3. Health status, perceived barriers, and support.
  4. Chief complaint (CC).
  5. History of present illness (HPI).
  6. Family and/or social history (PFSH).
  7. Focused review of systems (ROS).
    Clearly and comprehensively documents comprehensive health history, and presents
    complete information required for all of the seven categories (a-g) described in the
    assignment criteria. Data is clear, detailed, and in-depth.
  8. Identify age, spiritual values, and cultural variables that were considered and how these
    variables influenced your interviews or health history.
    Thoroughly presents complete information on age, spiritual values, and cultural variable.
    Describes in-depth and with supporting evidence how these variables influence the
    interview or health history.
    Thoughtfully analyzes and evaluates how to elicit the client’s interpretation of their health
    status. Draws warranted, judicious, non-fallacious conclusions. Identifies the salient
    arguments (perceived barriers and support) pro and con providing explicit examples and
    details.
    Thoughtfully critiques and evaluates the effectiveness of several history-taking techniques.
    Draws warranted, judicious, and non-fallacious conclusions. Information and evidence are
    accurate, appropriate.
    In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a
    patient’s health history. Include the following:
  9. Address how to elicit the patient’s interpretation of their health status, their perceived
    barriers, and support.
  10. Critique the effectiveness of several history taking techniques with rationale from the
    readings.
    Prepare this assignment according to the APA guidelines.

Comprehensive Health History Taking

In any medical setup, conducting patient’s interview and recording of necessary
information plays a fundamental role in the practitioner’s examination process. This process is
very crucial as it may affect the perception and the attitude of a patient. This paper therefore,

COMPREHENSIVE HEALTH HISTORY TAKING 2
discusses some of the effective interviewing techniques for collecting patients’ health
information.
Normally different patients visit health facilities with different ailments. The first step is
to establish a positive relationship with the patient. This is established by welcoming and
portraying respect. The tone of voice of the nurse should be calm and warm. This allows the
patient to feel relaxed to provide or explain the ailment (Brummel-Smith & Halperin, 2013). The
patient is the chief complainant and describes the significant signs or symptoms of illness.
During this interview, information from the patient is sourced including general health and
lifestyle, changes in health since the last visits to the hospital and medical and health history.
Other interviewing techniques or skills that one must posses include effective listening. It is
prudent for the nurse to be very attentive in listening, thinking about a certain aspect and when
responding (Both, et al 2009). This will ensure that important information is noted hence aiding
in proper medication. It is also important to be sensitive about nonverbal cues and body
language as they communicate a lot. Understanding these cues enhance the interview. It is also
essential for an individual to have broad knowledge base that will enable an individual to ask
relevant questions to stimulate more information and for clarification.
Other follows the eight steps of interviewing. It is important to carry out a research
before the interview by reviewing the records of the patients and ensure that all the test and lab
results are present on the chart. This ensures that important and relevant information is
available. The interview should be planned. Planning ensures that enough preparation is done
making it organized and to adhere to the stipulated rules. Planning also allows an individual to
have that confidence on how the interview will be done. The patient should be made to feel
relaxed and at ease. This can be achieved through eye contact and use of icebreakers. The

COMPREHENSIVE HEALTH HISTORY TAKING 3
advantage of this is that it allows the patient to give information better without feeling stressed
and depressed. The patient should then be requested for an interview. The importance of the
interview needs to be emphasized. The environment should be conducive and the interview
should be done under closed doors (Both, et al 2009). It is essential to be sensitive and respectful
when discussing certain topics through observing of nonverbal cues. The interviewer should not
give opinion and the interview should be confined within the scope. The last step is the
formulation of a general picture whereby key points are summarized. The patient should also be
given time to ask questions or to add more information on the topic of discussion.
During the interview, practitioners can ask open-ended questions. These questions require
more than a yes or no answer to allow the practitioner to get data that are more detailed.
Hypothetical questions are also used as they allow the practitioner to determine the knowledge of
the patient and establishing whether it is accurate or not. Restatement or mirroring is also
employed where the nurse states that which the patient said in ones own word (Both, et al 2009).
The patients need to be encouraged to take the lead in the discussion. This allows solicitation of
adequate information about the status of the patients. The patients should also be encouraged to
provide additional information and to evaluate the situation. The use of critical thinking skills is
also one of the effective interviewing techniques that can be used in the collection of health
information. The nurse should encourage verbalization of the concerns, should mirror response,
and restate the comments of the patient and verbalization what the nurse thinks the patient is
implying.
Eliciting clients’ interpretations of health status, their perceived barriers and support is
also essential when having an interview with them (Alspach, 2011). Some of the perceived
barriers that may hinder the client from engaging constructively in the interview include

COMPREHENSIVE HEALTH HISTORY TAKING 4
communication problems, anxiety lack of assurance of privacy and confidentiality of information
among others. The patients require better treatment and support to gain confidence by
establishing positive relationships and assuming that their information will remain confidential.
Patients too have their own way of looking at a problem or a health problem and it is essential to
identify this. This can be interpreted by listening attentively and observing the patient closely.
Close monitoring of non-verbal cues is also important when interpreting their health status. For
example when maintaining eye contact with the patients, one will be able to tell those the patient
is feeling or experiencing. A client suspected of being abused normally will speak in a guarded
way, while a depressed patient will exhibit various symptoms such as fatigue, loss of appetite;
lose of energy and profound sadness. Furthermore, client interpretation can also be known
through asking of hypothetical questions.
To illustrate the various aspects or information that is sort for from a patient that makes
up their health history, Andrew, one of my friends is adopted and suffers from depression.
Andrew is a middle-aged person and has been involved in numerous conflicts with his neighbors
on various issues relating to property ownership and threats of assassination. Signs and
symptoms began in the last two months after he lost one of the properties he owned in a court
due to lack of sufficient evidence. Andrew comes from an extended family and is married. He is
a charming individual that socializes well with others. The last time he visited the health facility
was a month ago. He was complaining of loss of appetite and sleep and general fatigue. Other
information that he provided included whether he had taken an insurance cover or not and any
other conditions or complication he had experienced. Andrew had no insurance cover and before
his ailment, he had never been diagnosed with a disease. Andrew who was the chief complaint
stated the significant symptoms and signs of his illness. Some of the symptoms and signs

COMPREHENSIVE HEALTH HISTORY TAKING 5
included difficulty in getting sleep, loss of energy and appetite, feeling of sadness and fatigue.
Focused review of systems is an inventory of certain body systems that physicians carry out to
identify the overlooked or forgotten symptoms in a patient (E/M University. (2013). Andrew was
also taken through this process to help the practitioner to find out on aspects that he did not
perceive to be part of his ailments such as measurement of his weight. Age, spiritual values and
cultural variables are factors that were also considered during this interview. Andrew is a
Christian and appreciates some cultural values. These variables influenced the interview because
they could have in one way or another played a role in his health. For instance, age is taken into
consideration when diagnosing depression. Depression is mostly prevalent amongst late
adolescent’s middle-aged people and people that have already retired.
In conclusion, interview on health history of patient is important in helping practitioners
to make appropriate decisions when it comes to treatment. During this interview, the
relationships between the client and the practitioner should be enhanced. This increases the
confidence of the client to share information with the practitioner. Listening and observing
nonverbal cues is central to a successful interview. Other factors such as the family and the
personal information about the client are important too.

References

Alspach, J. (2011). The importance of family health history: your patients’ and your own,
Critical Care Nurse, 31(1): 10-15.
Both, W., et al. (2009). Medical Assisting. Chapter 36: Interviewing the patient, taking a history,
and documentation, McGraw-Hill companies.

COMPREHENSIVE HEALTH HISTORY TAKING 6
Brummel-Smith, K., & Halperin, A. (2013). Patient-Centered Care for People with Cognitive
Impairment Is Possible in Primary Care, Generations, 7(3): 87-91.
E/M University. (2013).

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