NURS 6512 Module 1: Comprehensive Health History
NURS 6512 Module 1: Comprehensive Health History
What’s Happening in This Module?
This course is composed of four (4) separate modules. Each module consists of an overarching topic in which each week within the module includes specific subtopics for learning. As you work through each module, you will have an opportunity to draw upon the knowledge you gain in various Digital Clinical Experiences (DCE) and lab assignment components that will be due throughout each of the modules.
Module 1: Comprehensive Health History is a 1-week module, Week 1 of the course, in which you will examine how social determinants of health such as age, gender, ethnicity, and environmental situations 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.

What do I have to do?    
When do I have to do it?    

Review your Learning Resources
Days 1–7, Week 1

Discussion: Building a Comprehensive Health History
Post by Day 3 of Week 1, and respond to your colleagues by Day 6 of Week 1.

What’s Coming Up in Module 2: Looking Ahead
Review the “Looking Ahead” section for this week. You are encouraged to further review the requirements for the Shadow Health registration process for your digital clinical experiences.

Go to the Week’s Content
Week 1
 Week 1: 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), 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)
Welcome and General Course GuidelinesDr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m). NURS 6512 Module 1: Comprehensive Health History
Module 1 IntroductionDr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).
Building a Comprehensive Health History – Week 1 (19m)
Discussion: Building a Health History
Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
How would your communication and interview techniques for building a health history differ with each patient?
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.

Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion

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