Importance of Medical History for Treatment

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Introduction

Health histories are important in effective delivery of care. Healthcare professionals use effective communication, which helps in obtaining accurate health backgrounds of patients. Scholars suggest that nurses should be aware of the different factors that influence the onset and progression of illnesses (Ball, Dains, Flynn, Solomon & Stewart, 2014).

In fact, the knowledge about factors, such as age, ethnicity and gender, could be important in the establishment of good relationships with patients, which correlate with better health outcomes (Ball et al., 2014; Deeks, Lombard, Michelmore & Teede, 2009; Delpierre, Lauwers-Cances, Datta, Berkman & Lang, 2009). It would be essential for a clinician to assess potential risks of a patient because they help in building an extensive history. Although different risk assessment instruments are accessible, different tools are applicable in specific scenarios. This paper focuses on building a health history of a new patient.

55-year-old Asian female living in a high-density poverty housing complex

Potential risks

Before a clinician can establish a health history of the patient, it is essential to identify potential risks that face the patient. The risks in this context could have a basis on the age, ethnicity, gender, and environment of the patient. From a healthcare practitioner’s perspective, the patient could have the following risks: rape, STIs, water pollution, air pollution, industrial pollution, and frequent microbial infections. A nurse would consider all the risks when building the history of the 55-year-old patient.

One risk assessment instrument (HCR-20)

A clinician uses a risk assessment instrument to determine the chances of negative health impacts from certain factors. Several tools are important for the determination of risks. A healthcare worker would use HCR-20 to assess the patient in this discussion. The instrument has many structures, which are important in supporting many applications (LeBlond, Brown & DeGowin, 2009). It is available in more than twenty languages and has been in use in more than thirty-five countries across the world. In order to ensure that it keeps pace with developments in the healthcare industry, its developers update it on a regular basis.

In order for healthcare personnel to use it for the above patient, he or she would employ its ten historical features, five clinical aspects and five risk management attributes. Specifically, it is evident that the patient is living in a location that has a high poverty rate. Thus, healthcare personnel would expect the area to have relatively high rates of crime, which would negatively impact health outcomes of individuals. The risk assessment technique would be applicable in this context because it would help a nurse to identify the right information regarding the patient’s health history (LeBlond et al., 2009). In addition, it would be the best approach in this context because it would result in better clinical testing and evaluation that would lead to better health outcomes.

Communication and interview techniques

With regard to obtaining information that would form the basis of a healthcare history of the patient, it would be critical for a healthcare staff to use an effective interview and communication techniques (LeBlond, Brown & DeGowin, 2009). A face-to-face interview would be appropriate for the 55-year-old Asian female living in a high-density poverty housing complex. A nurse would use the type of interview because it would enable the patient and the healthcare personnel to meet (Lee, Neumann & Rizzo, 2010). Therapeutic communication techniques would yield best results with regard to obtaining important information from the patient.

A healthcare staff would select the strategies because they would be critical in offering broad openings that would culminate in high quality information. In addition, therapeutic communication approaches would have silence, which would be important in encouraging the patient to speak (LeBlond et al., 2009; Lee et al., 2010).

Questions that a nurse would ask the patient

  1. Are you married?
  2. Do you have children?
  3. Do you live with your family members?
  4. Are your family members supportive?
  5. What is your occupation?
  6. What is your annual income?
  7. What is the main source of your income?
  8. Have you been involved in crime?
  9. What is the crime rate in your locality?
  10. Do you take alcohol and/or drugs?
  11. What is the dominant ethnic group in your area of residence?
  12. Have you ever experienced sexual abuse?

Conclusion

In conclusion, health histories of patients are important in assisting nurses to offer better care. Excellent communication is key with regard to building accurate histories of patients. Therapeutic communication is important because it helps patients to give more information that clinicians use to develop health histories. In order to obtain more information, nurses should employ face-to-face interviews.

It would be critical for nurses to appreciate that various factors could impact the onset and progression of illnesses. Nurses apply different risk assessment techniques to obtain health histories from patients. However, different instruments can be applicable in unique situations of patients. Thus, clinicians should always aim at adopting risk assessment tools that would result in the best outcomes.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Web.

Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). . BMC Public Health, 9(3), 213–220. Web.

Delpierre, C., Lauwers-Cances, V., Datta, G. D., Berkman, L., & Lang, T. (2009). . American Journal of Public Health, 99(7), 1278–1284. Web.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical. Web.

Lee, D. W., Neumann, P. J., & Rizzo, J. A. (2010). Understanding the medical and nonmedical value of diagnostic testing. Value in Health, 13(2), 310–314. Web.

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