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Building a Health History: Communicating Effectively To Gather Appropriate Health-Related Information

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.

There may also be significant cultural factors. In May 2012, Alice Randall wrote an article for The New York Times on the cultural factors that encouraged Black women to maintain a weight above what is considered healthy. Randall explained from her observations and her personal experience, as a Black woman, that many African American communities and cultures consider women who are overweight to be more beautiful and desirable than women at a healthier weight. As she put it, “Many black women are fat because we want to be” (Randall, 2012).

Randall’s statements sparked a great deal of controversy and debate at the time; however, they emphasize an underlying reality in the healthcare field: Different populations, cultures, and groups have diverse beliefs and practices that impact their health. APRNs and other healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.

As an advanced practice nurse, you must build a patient health history that takes into account all of the factors that make a patient unique and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with each patient, but it will also enable you to more effectively gather the information needed to assess a patient’s health risks.

For this first Assignment, you will take on the role of an APRN who is building a health history for a particular patient assigned by your Instructor. You will consider how social determinants of health and specific cultural considerations will influence your interview and communication techniques as you work in partnership with the patient to gather data for an accurate health history.

Note: You are expected to draw on the resources for both Week 1 and Week 2 when completing your Assignment.

To prepare:

• Reflect on your experience as an advanced practice nurse and on the information provided in the Week 1 Learning Resources on building a health history and the Week 2 Learning Resources on diversity issues in health assessments.
• By Day 1 of this week, your Instructor will assign a case study for this Assignment. Note:Please see the Course Announcements section of the classroom for your Case Study Assignment.
• Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of your assigned patient.
• Consider how you would build a health history for the patient. What questions would you ask? How might you target your questions based on the patient’s social determinants of health? How would you frame the questions to be sensitive to the patient’s background, lifestyle, and culture?
• Identify any potential health-related risks, based on the patient’s age, gender, ethnicity, or environmental setting, which should be taken into consideration.
• What risk assessment instruments would be appropriate to use with this patient?
• What questions would you ask to assess the patient’s health risks?
• Select one (1)risk assessment instrument discussed in the Learning Resources, or another tool with which you are familiar, related to your selected patient.
• Develop five (5)targeted questions you would ask the patient to build their health history and to assess their health risks.
• Think about the challenges associated with communicating with patients from a variety of specific populations. What communication techniques would be most appropriate to use with this patient? What strategies can you as an APRN employ to be sensitive to different cultural factors while gathering the pertinent information?

Assignment: Building a Health History With Cultural and Diversity Awareness  

Include the following: 

• Explain the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Be specific.
• Explain the issues that you would need to be sensitive to when interacting with the patient, and why.
• Describe the communication techniques you would use with this patient. Include strategies to demonstrate sensitivity with this patient. Be specific and explain why you would use these techniques.
• Summarize the health history interview you would conduct with this patient. Provide at least five (5)targeted questions you would ask the patient to build their health history and to assess their health risks. Explain your reasoning for each question and how you frame each for this specific patient.
• Identify the risk assessment instrument you selected, and then justify why it would be applicable to your assigned patient. Be specific.

Readings:

• 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.). Elsevier Mosby.
  • Chapter 2, “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.
• i-Human Patients. (2023). i-Human Patients case player: Student manualDownload i-Human Patients case player: Student manual. I-Human Patients by Kaplan.
  Note: This link provides a PDF download for this manual.
• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis Company.
  • Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

• 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.). Elsevier Mosby.
  • Chapter 1, “Cultural Competency”
    This chapter highlights the importance of cultural awareness when conducting health assessments. The authors explore the impact of culture on health beliefs and practices.
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th edition by Dains, J. E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
  • Chapter 2, “Evidenced-Based Clinical Practice Guidelines Download Evidenced-Based Clinical Practice Guidelines”
• i-Human Patients. (2023). i-Human Patients case player: Student manual Download  i-Human Patients case player: Student manual. I-Human Patients by Kaplan.
  Note: This link provides a PDF download for this manual.