Module 1 Assignment: Taking a Health History: Building a Health History: Asking Difficult Questions
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Module 1 Assignment: Taking a Health History: Building a Health History: Asking Difficult Questions
The first step in the nursing process is taking the health history of the patient for further understanding of their reason behind visiting the hospital. It involves collecting important personal information from the patient which is used in clinical reasoning and decision making. It may involve asking the patient difficult questions which require appropriate communication skills and the application of appropriate professional competencies (Kruse et al., 2018). This paper demonstrates a script for building the health history of a volunteer playing the role of a patient.
Part 1: A-Health History
Personal Information
- What is your name?
- How old are you?
- What is your marital status?
- Where do you stay?
Personal Health History
- Do you have any chronic illnesses?
- Did you have any childhood illnesses?
- What are your current physical symptoms?
- Are you taking any medication now?
- Are you allergic to any drug or food or environmental factors?
- Which medical conditions run in your family?
- Do you live alone?
- Have you ever undergone any surgical procedure?
Health Habits and Personal Safety History
- How regularly do you engage in physical activity/exercise?
- Do you maintain a balanced diet?
- Do you smoke tobacco, drink alcohol, or use any other illicit drug of abuse?
Sexual Health History
- Are you sexually active?
- What is your sexual orientation?
- Do you take any contraceptives? Which one?
- Do you have a history of any sexually transmitted diseases?
- Are your menses regular?
Other Assessments
- Are your immunizations up to date?
- Perform physical examination based on the findings of the subjective data.
Part 1: B-Experience
Developing the health history script for the patient was quite challenging given that only relevant questions need to be asked. Construction of questions requires the use of polite language to make a conducive environment for the patient to be free and open to provide accurate information crucial in decision making (Tessier et al., 2019). It is also important to focus the question on the patient’s chief complaint to be able to build on their main health concern, before assessing other possible complications. Consequently, to comply with the HIPPA regulations, it is very important to observe ethical considerations when asking a question that involves sensitive matters such as sexual orientation and gender, which are considered difficult questions, especially among culturally diverse patients to promote a healthy patient-provider relationship.
Part 2: Reflection
LGBTQs are regarded a vulnerable population because of the prejudice and discrimination they receive from other members of society. Routine women’s health examination for this population will involve screening for pregnancy, changes in body weight, osteoporosis, and breast cancer among others. Some applications that can be used for pregnancy screening include Sprout Pregnancy, Pregnancy App Preglife, and My Pregnancy among others (Bouayad et al., 2017). Applications that can be used for anxiety screening include Calm. Colorfy, and Dare, among others. These tools help promote easily accessible screening services to promote the health and safety of vulnerable populations. These applications are compliant with the HIPPA guidelines promoting patient safety and confidentiality, by providing accurate information which is protected from unauthorized personnel.
References
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.
Kruse, C. S., Stein, A., Thomas, H., & Kaur, H. (2018). The use of electronic health records to support population health: a systematic review of the literature. Journal of medical systems, 42(11), 1-16. https://doi.org/10.1007/s10916-018-1075-6
Tessier, L., Brehaut, Jamie C., Potter, Beth K., Chakraborty, P., Carroll, June C., & Wilson, Brenda 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
