Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables:
- Identifying data.
- Past medical history.
- Health status, perceived barriers, and support.
- Chief complaint (CC).
- History of present illness (HPI).
- Family and/or social history (PFSH).
- Focused review of systems (ROS).
- Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history.
In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient’s health history. Include the following:
- Address how to elicit the patient’s interpretation of their health status, their perceived barriers, and support.
- Critique the effectiveness of several history taking techniques with rationale from the readings.
Expert Solution Preview
As a medical professor, one of the tasks I assign to my students is to prepare a comprehensive health history of a patient. The health history should include identifying data, past medical history, health status, perceived barriers, and support, chief complaint, history of present illness, family and/or social history, and focused review of systems. In this answer, I will provide guidance on how to prepare a comprehensive health history and effective interview techniques for collecting a patient’s health history.
When preparing a comprehensive health history, it is important to start with identifying data such as name, age, sex, race or ethnicity, occupation, and marital status. Afterward, ask about the patient’s past medical history, which should include details on any surgeries, hospitalizations, allergies, medications, and chronic illnesses. Additionally, inquire about the patient’s health status, such as current medications, perceived barriers to good health, and social support.
Next, identify the patient’s chief complaint, which is the main reason they are seeking medical attention. To gather information on the history of present illness, ask open-ended questions to determine the timeline, severity, and onset of symptoms.
The family, personal, and social history (PFSH) can provide crucial information on the patient’s current condition and risk factors. Be sure to ask about the history of tobacco, alcohol, and drug use, as well as any occupational or environmental exposure to toxins.
Lastly, conduct a focused review of systems (ROS) by asking specific questions concerning each body system. This includes questions about the respiratory system, cardiovascular system, digestive system, neurological system, and others.
During the interview process, it is important to consider the age, spiritual values, and cultural background of the patient. Ask questions in a culturally sensitive and appropriate manner and use interpreters if necessary. Effective interview techniques include active listening, using open-ended questions, avoiding medical jargon, establishing rapport, and maintaining a professional yet friendly tone.
To elicit the patient’s interpretation of their health status, ask how they feel about their current health and if there is anything that concerns them. Inquire about any barriers they face in maintaining good health, such as financial constraints or access to healthcare. Additionally, ask about their support system, including family, friends, and community resources.
Several history-taking techniques include the CAGE questionnaire, which screens for alcohol abuse, and the HEEADSSS assessment tool, which assesses social and mental health aspects in adolescents. However, the effectiveness of these techniques can vary based on the patient population and situation. Therefore, it is important to select a history-taking tool that is appropriate for each patient’s unique set of circumstances.
In conclusion, collecting a patient’s health history is an important aspect of providing effective medical care. It involves gathering detailed information on the patient’s medical history, current health status, and social support. Adopting effective interview techniques and using culturally sensitive approaches can enhance the accuracy of the collected information, ultimately leading to more effective care.