Discussion: Building a Health History NURS 6512N
Discussion: Building a Health History
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. As an advanced practice nurse, you must be aware
of these factors and tailor your communication techniques accordingly. Doing so will not
only help you establish rapport with your patients, but it will also enable you to more
effectively gather the information needed to assess your patients’ health risks.
For this Discussion, you will take on the role of a clinician who is building a health
history for a particular new patient assigned by your Instructor.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
By Day 1 of this week, you will be assigned a new patient profile by your
Instructor for this Discussion. Note: Please see the “Course Announcements”
section of the classroom for your new patient profile assignment.
How would your communication and interview techniques for building a health
history differ with each patient?
How might you target your questions for building a health history based on the
patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient,
or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender,
ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter
5 of the Seidel's Guide to Physical Examination text, or another tool with which
you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to
assess his or her health risks and begin building a health history.
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques
you would use with your assigned patient. Explain why you would use these techniques.
Identify the risk assessment instrument you selected, and justify why it would be
applicable to the selected patient. Provide at least five targeted questions you would ask
the patient.
Note: For this Discussion, you are required to complete your initial post before you will
be able to view and respond to your colleagues’ postings. Begin by clicking on the "Post
to Discussion Question" link, and then select "Create Thread" to complete your initial
post. Remember, once you click on Submit, you cannot delete or edit your own posts,
and you cannot post anonymously. Please check your post carefully before clicking
on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a
different patient than you, using one or more of the following approaches:
Share additional interview and communication techniques that could be effective
with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion
What's Coming Up in Module 2?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 2, you explore the impact of functional assessments, diversity, and sensitivity
in conducting health assessments. You also examine various assessment tools and
diagnostic tests used to gather information about patients’ conditions and examine their
validity, reliability, and impact in conducting health assessments.
Next week, you will specifically examine functional assessments as they relate to
diversity and sensitivity
Registration for Shadow Health
Throughout this course, you will participate in digital clinical experiences using the
online simulation tool Shadow Health. The Shadow Health digital clinical experience
provides a dynamic, immersive experience designed to improve nursing skills and
clinical reasoning through the examination of digital standardized patients. Using
Shadow Health you will participate in health histories, focused exams, and a
comprehensive assessment.
There will be four Shadow Health assessment components that you will need to
complete in Module’s 2 and 3:
Health History Assessment (Week 3 & 4)
Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest
pain
Comprehensive (Head-to-Toe) Physical Assessment (Week 9)
Before you can participate in these simulations, you will need to register for a Shadow
Health account. To do this:
Go to the Walden Bookstore and purchase access to Shadow Health and the
required texts.
Once Shadow Health has been purchased, an access code will be emailed to
you from the bookstore.
Review this video explaining how to register in Shadow
Health: https://vimeo.com/275921826/c12d50ee6e
Use the Shadow Health link located in the navigation menu on the left in the
Blackboard course.
Follow the prompts to register in Shadow Health. You will need the access code
provided from the bookstore to register. Once registered, Shadow Health should
always be accessed via the link in Blackboard.
Use only Google Chrome when accessing Shadow Health and make sure all
other programs are turned off on your computer. Other browsers do not work well
and will not allow the Shadow Health speech to text function to work.
Once registered, complete the Shadow Health Orientation in the Shadow Health
website/program and review the videos designed to assist with navigating and
completing assignments.
Read the Shadow Health Nursing Documentation Tutorial located in the Week 1
Learning Resources.
Note: As nurses you typically use the word assessment to mean completing the
physical exam. However, in the SOAP Note format, assessment means diagnosis so
start getting in the habit of calling the physical exam exactly that.
Week 2 Case Studies
In Week 2, your Instructor will assign you a case study related to your Discussion by
Day 1 of the week. Please make sure to review the “Course Announcements” area of
the course to verify your assigned case study. Please plan ahead to ensure you have
time to review your case study and your Learning Resources so that you can complete
your Discussions and Assignments on time.
Learning Resources
Required Readings (click to expand/reduce)
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)
Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P.,
Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are
of limited value to predict decline in functional status and quality of life:
Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-
org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk
assessments with family health history: Barriers and benefits.
Postgraduate Medical Journal, (1079), 508–513.
Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health
history: Using the past to improve future health. Public Health Reports, (1),
3.
Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem,
B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of
cardiovascular risk factors in health professionals: 20-year follow-up. BMC
Public Health, 15(1111), 1–7. https://doi-
org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Shadow Health Nursing Documentation Tutorial (Word
document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin's
diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.
Chapter 2, "History Taking and the Medical Record" (pp. 15–33)
Required Media (click to expand/reduce)
