Taking a Health History: Building a Health History

 

Taking a Health History: Building a Health History: Asking Difficult Questions

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Taking a Health History: Building a Health History: Asking Difficult Questions

Introduction

Collection of health history involves getting personal information that focuses on the symptoms being experienced by the patient.  Taking a health history is the first is procedure nurses must do when a patient visits a healthcare facility and involves observation and assessment to gather in-depth subjective information (Tessier et al., 2019). Therefore it is a fundamental skill for nurses. Taking comprehensive health information consists of asking difficult questions that help build a health history specific to a patient.  It is a form of interview that facilitates the collection of data. Therefore nurses should have proper interpersonal and communication skills to enhance data collection and deal with challenges and barriers faced during the process.   Additionally, building a patient’s health history is essential to improve workflow and provide the best treatment and care.

Health History

Taking a health history involves building a health history, conducting a physical examination, and documenting the acquired information. The health history is made up of subjective data about what the patient is experiencing any patient symptoms.  The data obtained in this stage is preliminary and personal information. During this stage, nurses need to enable a patient to feel comfortable and build a rapport with the patent to set a good tone for the interview. It makes the patient more open and honest without withholding information. Hence, the way an interview begins high determines the patient’s quality of data and openness (Bouayad et al., 2017).  When creating a health history, formal language is required, which enables getting the correct response. It is essential to use language which makes the patient comfortable even when dealing with shameful information, such as especially when dealing with sexual illness.

When collecting patient history, nurses should ensure the privacy and confidentiality of the patient information. In the United States, the Health Insurance Portability and Accountability Act of 1996 (or HIPAA) legislation provides patients have privacy and adequate safeguarding of patient medical information. It makes sure the healthcare professionals do not share or use patient information without the patients’ consent. The script provides information recorded in secure databases as patient records that are only accessed by qualified physicians and nurses treating the patients. According to Adler-Milstein & Nong (2019), this concept makes the patient comfortable and open to providing accurate answers rather than lying during an interview. Additionally, physician-patient rules enhance, and confidentiality is another way to create a conducive environment for the patient to be open about their health issues and provide proper answers even to complex questions.

 

Personal Information

  1. What is your name?
  2. What is your gender?
  3. What is your age?

Personal Health History

  1. Do you have any childhood illnesses?
  2. Have you received complete immunizations?
  3. What physical symptoms is the patient experiencing?
  4. Does the patient have a previous diagnosis or hospitalizations?
  5. Has the patient undergone significant treatment or surgery?
  6. What medication, if any, is the patient taking?
  7. Does the patient have any allergies medicinal or environmental allergies?
  8. What is the family history of illness?

Health Habits and Personal Safety History

  1. How regularly do you exercise?
  2. Do you take a balanced diet?
  3. Any history of alcohol consumption?
  4. History of tobacco use?
  5. How much caffeine do you consume?
  6. Do you take any legal and illegal drugs?

Sexual health History

  1. Are you sexually active?
  2. Do you practice safe sex?
  3. Do you experience any discomfort with sexual intercourse?
  4. Have you ever contracted any sexually transmitted disease?
  5. Have you ever received any treatment for a sexually transmitted disease?
  6. Do you live alone
  7. Do you have vision or hearing loss?

Family health history

  1. Have you ever experienced mental or physical abuse?
  2. What is the family history of illness?

Mental Health

  1. Do you feel depressed?
  2. Is stress a problem for you?
  3. Do you have problems with your appetite?
  4. Do you have suicidal thoughts or ever thought of hurting yourself?
  5. Do you have a sleeping problem?
  6. Have you ever sought counseling and therapy help?

Physical Examination

Physical history is a health basement that involves practicing extended roles of physically examining the patient to identify the underlying condition that may cause the patient’s condition (Ntando, 2017). The examination begins from head to toe, and different healthcare professionals use various tactics and skills.  Generally, the physical study aims to consistently ensure a unique systematic approach that ensures the healthcare professional does not miss any vital assessment area (Adler-Milstein & Nong, 2019). The physical examination approach of collecting data includes taking the complete vital signs, which provides for.’

  1. Measuring the height and weight of the patients
  2. Taking the body temperature
  3. Measuring the heart rate
  4. Taking the respiratory rate
  5. Measuring the blood pressure of the patient

All the above vital sign measurements are done immediately, a patient reaches the healthcare facility.  The following physical examination is assessing the patient level of pain. It involves asking direct questions, which includes

  1. What causes the pain, and what factors provoke the pain level?
  2. What is the pain quality, which includes describing the pain with unique phrases such as pain burning, pinching, throbbing, or stabbing?
  3. Is the patient radiant from one part of the body to another?
  4. What are the severity of the pain and other symptoms being experienced alongside the pain?
  5. What is the timing of the pain? Is it constant, or does it get better or worse?

Physical examination is accompanied by the patient’s specific health history, especially any information about the body system. This includes asking physical exam questions, which helps in assessment while exploring the various parts of the body. The assessment includes;

  • Skin assessment is done through a physical examination to provide findings of any problems with the skin. Skin assessments crucial to identify areas of the body with a problem as it is easier to identify a skin vulnerability through observation by the patient and healthcare professional. The following questions are asked during a physical skin assessment:
  1. Have you experienced any general pigmentation on the skin?
  2. Have you observed any color changes on the skin?
  3. Are you experiencing any pain in any part of the skin?
  4. Have you observed any lesions or moles in the skin?
  • The physical assessment also includes HEENT assessment. Eyes, Ears, Nose, and Throat examination focuses on the problems identified by a patient while providing personal information. The following question is asked during the HEENT assessment:
  1. Do you experience headaches?
  2. Have you ever injured your head?
  3. Any pain in the eye?
  4. Any change in vision such as double or blurred vision?
  5. Any swelling, redness, or inappropriate discharge in the eyes?
  6. Have you had any hearing problems or ear infections in the past?
  7. Do you have any year discharge or ringing in the ear?
  8. Do you have occupational exposure to too much noise?
  9. Any nasal discharge or allergies?
  10. Do you get frequent nose bleeds and colds?
  11. Do you frequently experience nasal pain?
  12. Do you have problems with your throat, such as tonsils or throat soreness?

Documentation of health history

Building history also involves documenting the collected data, which healthcare professionals use to inform the patient’s subsequent treatment. Additionally, it helps in determining and reporting the healthcare provided by the patient.  Answering questions either by mouth or writing is a good way of expression. Healthcare professionals can obtain details that create a concise and compelling history of a patient who plays a crucial role in the treatment and ensures their health (Bouayad et al., 2017).  A healthcare professional analyses the acquired information to know what is wrong with the patient health-wise, which helps to synthesize proper diagnosis and treatment. A healthcare professional can focus on specific aspects of a patient, which helps create a patient-based plan of care unique to each patient based on their diagnosis. Therefore, the health history is an efficient and effective record that provides relevant information to ensure a proper diagnosis; provision of appropriate care is enacted for all patients.

Part 2: Reflection

After understanding how to create a patient’s health history, it is crucial for healthcare professionals to know how to use the data collected to provide quality treatment and care services to the patient.  Also, collecting health history is essential as it involves observation and assessment, which are two crucial aspects of diagnosis and treatment (Ntando, 2017). The experience of developing the patient history script is critical to make sure relevant questions are asked to provide the required information for proper diagnosis. When the data is gathered, appropriate methods of implementing and using the collected information are needed to avoid repeating the same process when a patient revisits healthcare. It means proper documentation and storage of acquired patient information, which can be easily assessed when needed.

Building a health history is very enlightening and provides a different aspect of other patients’ clinical part. Understanding how to make a health history opens a healthcare professional’s mind to use their additional essential knowledge and experience, especially when asking difficult and shy questions. Also, it provides nurses with clinical contexts of the patient by identifying different patient components by getting comprehensive information crucial for making a proper diagnosis.  According to Goffman et al. (2017), the process of generating health history has enabled healthcare professionals to use and improve their therapeutic communication and rapport skills in healthcare. This has improved interaction with patients, which enhances proper diagnosis and appropriate treatment for a better outcome.  The patients trust healthcare professionals and feel free to talk about their health issues despite providing answers.

When a healthcare professional becomes familiar with the health history through appropriate assessment, it becomes easier to use the knowledge and consider specific aspects of the patient to provide effective services and create a treatment and care plan using obtained health history. Developing health history includes expertise and experience in effective questioning and applying interpersonal abilities to have confidence when dealing with different patients with different beliefs, cultures, and backgrounds, which influences the patients’ ability to answer difficult questions.

Also, the experience helps to describe the importance of effective questioning and application of various skills learned skills to derive the required answers from the patients. A healthcare professional can directly ask unique and embarrassing questions without fear or difficulty. After creating a good rapport with the patient, it becomes easier for the patent to provide answers, incredibly complex problems (Tessier et al., 2019). Additionally, the process helps identify and solve various healthcare challenges, especially when dealing with uncomfortable health issues. Also, it enhances the ability to communicate and ask for efficient information, facilitating treatment despite the discomfort being experienced.

When asking the question, getting the clients to open it was difficult, especially when asking for private information, which is hard to share. It becomes challenging to get answers when the patient ignores their health issues. They are not aware of the symptoms’ onset, or the patients lie about their problems, making it challenging to generate a proper diagnosis and treatment plan. Additionally, when dealing with old patients and children who cannot express their symptoms or answer the question, it becomes difficult interpretation or getting information.  Therefore, it is essential to create a proper rapport with the patient to develop trust and openness. Additionally, it is crucial to inform the patient of their right to protect their information provided by the HIPPA legislation, which encourages openness to answer difficult questions about themselves.

 

 

References

Adler-Milstein, J., & Nong, P. (2019). Early experiences with patient-generated health data: health system and patient perspectives. Journal of the American Medical Informatics Association, 26(10), 952-959. https://doi.org/10.1093/jamia/ocz045

https://academic.oup.com/jamia/article-abstract/26/10/952/5476189

Bouayad, L., Ialynytchev, A., & Padmanabhan, B. (2017). Patient health record systems scope and functionalities: literature review and future directions. Journal of medical Internet research, 19(11), e388. doi: 10.2196/jmir.8073

https://www.jmir.org/2017/11/e388/

Goffman, R. M., Harris, S. L., May, J. H., Milicevic, A. S., Monte, R. J., Myaskovsky, L., … & Vargas, D. L. (2017). Modeling patient no-show history and predicting future outpatient appointment behavior in the veteran’s health administration. Military medicine, 182(5-6), e1708-e1714.  https://doi.org/10.7205/MILMED-D-16-00345

https://academic.oup.com/milmed/article/182/5-6/e1708/4158896?login=true

Ntando, E. A. (2017). Application of communication skills in an authentic clinical setting: assessing the sixth-year medical students’ communication competency during history taking (Doctoral dissertation). https://ukzn-dspace.ukzn.ac.za/handle/10413/17284

Tessier, L., Brehaut, J. C., Potter, B. K., Chakraborty, P., Carroll, J. C., & Wilson, B. J. (2019). Family History Taking in Pediatric Practice: A Qualitative Interview Study. Public health genomics, 22(3-4), 110-118. https://doi.org/10.1159/000503729

https://www.karger.com/Article/Abstract/503729

Virgolino, A., Roxo, L., & Alarcão, V. (2017). Facilitators and barriers in sexual history taking. In The Textbook of Clinical Sexual Medicine (pp. 53-78). Springer, Cham.  DOIhttps://doi.org/10.1007/978-3-319-52539-6_5

https://link.springer.com/chapter/10.1007/978-3-319-52539-6_5

 


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