Health History

Health Assessment RUA
April 29, 2024
Health Informatics Standards
April 29, 2024
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Health History

Introduction

The purpose of gathering a patient’s health history is to obtain subjective data concerning the patient to enable the health care providers and the patient to collaboratively design a health plan that promotes health, addresses acute health issues and reduces the risk for developing chronic health issues. This process involves gathering an individual’s psychological, physiological, spiritual and sociological needs. By doing so, a health provider is able to identify both current and future patient needs by forming a nursing diagnosis. This aid in prioritizing interventions and care and improves health outcomes (Jamieson et al., 2019).

Reflection
Before this interview, I tried to manage my expectations due to the sensitive and personal type of information I would be asking from the interviewee. Health is an important aspect in any individual’s life and it is crucial that they are aware of their health status in order to shape their lifestyles for better outcomes. I expected and hoped that the subject would be conscious of these details and provide the answers to my questions with relative ease. The interview took place in a Doctor’s office which was well lit, comfortable, private and quiet. It took around 30 minutes and started at around noon. I sat at a comfortable distance and angle from the interviewee so as to respect their personal space but still foster communication. To establish rapport, I spoke in a warm but professional tone, making eye contact while allowing the interviewee time to answer my open-ended questions. My demeanor was respectful, non-judgmental and without interruption.

The interaction was smooth as the interviewee had some medical background and was motivated to improving his health and overall lifestyle. However, in the latter stages, the interviewee grew restless owing to the fact that he complained of sore throat and dryness. Another contributing factor might have been the allergies that the patient had recently developed. The information I learnt in class helped me prepare for the interview beforehand and also helped me anticipate some of the problems I would have while conducting the interview.

One of the barriers to communication that I experienced was having to explain medical jargon in a different manner than he was accustomed to in his military health background. In order to avoid inaccuracies or incorrect information, I had to use the restatement and summarizing technique to clarify the information given by the interviewee. In the future, this obstacle can be evaded by avoiding medical jargon as much as possible to avoid potential embarrassment every time the patient asks for clarification. The interviewee can also be encouraged to ask any questions at any stage of the interview.
The interview went well on a few levels. The rapport was there, the patient looked comfortable and the interview did not take long. The interviewee also provided a lot of the information asked and had a high willingness to participate due to the willingness to change his lifestyle for the better. However, despite this, there were a few unexpected challenges. The interview was interrupted twice by hospital staff looking for a Doctor. This interrupted the flow of the conversation and also brought about privacy concerns for the interviewee. This could have been avoided by conducting the interview in a private examination room or having a ‘interview in progress’ sign outside the door. For this interview, I had all the information I needed and was aided by the interviewee’s knowledge of his and his family’s health history. In preparation for next time, I will make sure to have a glass of water provided to the interviewee to increase their comfort. It would also be helpful to conduct the interview in a private room to avoid interruptions. Finally, I would try to use phrases and terms familiar to the individual and try to encourage them to be detailed and specific in their responses.

 

Reference

Jamieson, H., Abey-Nesbit, R., Bergler, U., Keeling, S., Schluter, P., Scrase, R., & Lacey, C. (2019). Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National Home Care Assessment Database of Older Adults. Journal Of The American Medical Directors Association20(11), 1419-1424. doi: 10.1016/j.jamda.2019.02.005