NURS 6512 Building a Comprehensive Health History

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NURS 6512 Building a Comprehensive Health History

NURS 6512 Building a Comprehensive Health History

 

According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in
the United States. One of the most admired nursing skills is the ability to put patients at
ease. When patients enter into a healthcare setting, they are often apprehensive about
sharing personal health information. Caring nurses can alleviate the hesitance of
patients and encourage them to be forthcoming with this information.
The initial health history interview can be an excellent opportunity to develop supportive
relationships between patients and nurses. Nurses may employ a variety of
communication skills and interview techniques to foster strong bonds with patients and
to effectively facilitate the diagnostic process. In conducting interviews, advanced
practice nurses must also take into account a range of patient-specific factors that may
impact the questions they ask, how they ask those questions, and their complete
assessment of the patient’s health.
This week, you will consider how social determinants of health such as age, gender,
ethnicity, and environmental situation impact the health and risk assessment of the
patients you serve. You will also consider how social determinants of health
influence your interview and communication techniques as you work in partnership with
a patient to gather data to build an accurate health history.
Learning Objectives
Students will:
 Analyze communication techniques used to obtain patients’ health histories
based upon social determinants of health
 Analyze health-related risk
 Apply concepts, theories, and principles related to patient interviewing, diagnostic
reasoning, and recording patient information

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),

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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)

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