NURS 6512 Discussion: Building a Health History

NURS 6512 Discussion: Building a Health History

The goal of this discussion is to grasp effective patient communication. To create a health history, getting accurate information might rely on how well a healthcare provider communicates with a patient. Additionally, I’ll pinpoint a risk assessment tool and explain why it’s suitable for the designated patient. Lastly, I’ll draft five specific questions to ask this patient.

Interview Synopsis

A pregnant Native American woman, aged 38, residing on a reservation, visits a healthcare facility for evaluation. As an Advanced Practice Registered Nurse (APRN), I’ll consider factors like gender, age, ethnicity, and surroundings while compiling a thorough health history (Ball et al., 2019). Being a male practitioner, I acknowledge my limitations in fully grasping a pregnant woman’s experiences. Hence, I’ll approach with compassion. I’ll gather medical history, procedures, substance use, prenatal care, medications (past and present), sexual habits, home life, diet, and any needed resources for proactive healthcare. I’ll ensure an open environment, allowing the patient space and silence to express concerns, ask questions, and provide information.

Communication Techniques Description

Effective communication involves understanding information exchanged among parties (Bramhall, 2014). Communication methods can significantly impact a patient’s treatment. I’ll recognize any barriers between the patient and myself. Assessments may induce discomfort, leading to ambiguous responses. Patients might feel agitated and seek understanding and attentive listening. I’ll sit at eye level, speak softly, and attentively take notes. I’ve noticed others distracted during assessments, which can hinder patient rapport and information gathering. According to the Joint Commission, 80% of serious medical errors occur due to poor communication during transfers (Commission, 2019). I’ll employ the teach-back method to ensure accurate understanding.

Rationale for Using Specific Techniques

I’ll employ these techniques to establish a connection with the patient. I believe every patient deserves to feel acknowledged and heard. In my experience, when patients feel valued and secure, they’re more open to communication. This bond can lead to successful treatment plans, patient safety, and consistent care.

Applicable Risk Assessment Instrument for the Patient

I’ll utilize the PRAMS Pregnancy Risk Assessment Monitoring System tool. This tool evaluates risks for both the patient and the baby, offering insights for universal healthcare adjustments and optimal patient outcomes. PRAMS covers crucial aspects of pregnancy, such as preconception health, folic acid awareness, HIV testing, employment, infections, chronic conditions, stressors, and physical activity (Shulman, 2006). Given the patient’s pregnancy status, these questions are pertinent and can benefit pregnant patients broadly.

Five Targeted Questions for the Patient

1. What brings you here today? I’ll ask to encourage open communication and ensure all concerns are addressed.
2. Do you have any medical conditions or diagnoses, either personal or in your family history?
3. What medications are you currently taking, or have you recently stopped? I’ll cross-reference with a pharmaceutical database for accuracy.
4. Do you have any allergies to food, medication, or other substances? If so, what are your reactions?
5. Before we conclude, is there anything else you’d like to share or ask?

In Conclusion

To sum up, I’ll approach the assessment with compassion, gauge the patient’s communication abilities, utilize tools as needed, and inquire to gather essential information for optimal patient outcomes.

Documentation – Tina Jones Neurological Shadow Health assessment

NURS 6512 Discussion: Building a Health History

Week One Discussion

     The purpose of this discussion is to understand effective patient communication. To build a health history, obtaining accurate information may depend on a health care provider’s ability to communicate with a patient. I will also identify a risk assessment instrument and why it is applicable for the assigned patient. Lastly, I will provide five targeted questions to ask this patient.

Summary of interview

     A Native American pregnant woman who is 38 years old living on a reservation arrives at a health care facility for evaluation. As an APRN, I would consider gender, age, ethnicity, and environmental factors while building a good health history (Ball et al., 2019). As a male practitioner, I cannot fully understand what a pregnant woman is experiencing. Therefore, my approach will be compassion. I will request medical diagnostic history, procedures, drug, tobacco, alcohol consumption, prenatal care, medications past and current, sexual practices, home life, nutrition intake, and resources they may need to be proactive with their healthcare. I will also ensure open space and silence from myself to allow the patient to express concerns, ask questions, and provide information.

Description of Communication Techniques

Clear communication requires understanding the information shared between two or more parties (Bramhall,2014). Communication techniques can make a difference in a patient’s treatment. I will become aware of the barriers between myself and the specific patient. Assessments may be uncomfortable for a patient, and so they may not be black and white. A patient could become angry and desire to understand and listening from myself. I will sit in a chair at eye level to the patient, listen, speak softly, and be aware while taking notes. I often notice others on a device or taking notes while an assessment is ongoing, and I believe that can cause a disconnect. A disconnect with a patient can likely impact the opportunity to obtain patient information. A report by the Joint Commission found that when patients get transferred, and there is a foundation of poor communication, 80% of serious medical errors occur (Commission,2019). I will utilize the teach-back method throughout the exam. Ensure that accurate communication is received.

The reasoning for Utilizing these Specific Techniques

I will be utilizing these specific techniques to connect with the patient. I believe a patient desires and has a right to be seen and heard. From my experience, when a patient feels seen, heard, and safe, they are open to communicating. This connection and dynamic can allow for successful treatment plans, patient safety, and continuity of care.

Risk Assessment Instrument and why it is Applicable for Patient

    I will utilize the PRAMS Pregnancy Risk Assessment Monitoring System tool. The tool assesses risks to consider for the patient and baby. I appreciate this resource as it is also a survey that allows for universal health care adjustments and best patient outcomes. PRMAS provides important considerations for women during pregnancy. Questions provided by the tool include but are not limited to preconception health and health care, folic acid awareness, HIV testing, work, leave, and childcare, infections, chronic conditions, stressful life events, and physical activity (Shulman,2006). This tool is applicable for the patient because they are pregnant, so the questions are essential and can assist pregnant patients across the board. Early intervention can be the difference in best patient outcomes.

Five Targeted Questions to Ask Patient

  1. What are the reasons for your visit today? I will ask the question as if there is more than one reason for the patient to feel at ease with sharing and communicating. I will consider what the patient shares and then assess the patient appropriately, ensuring that I am open to all possibilities.
  1. Do you have a history of medical conditions and or a medical diagnosis? Do you have a family history of disease?
  2. What medications are you currently taking, are they recently stopped, and I would also verify using resources that check a pharmaceutical database.
  3. Do you have any allergies to food, medication, substances, and if so, what happens when they have an allergic reaction. For example, some consider stomach aches after ingesting medicine an allergic reaction, so I will decipher.
  4. Is there anything you would like to share or ask me before we finish this assessment? I believe that allowing for an open-ended question can provide important information not obtained.


In conclusion, I will assess with compassion, understand the patient’s abilities to communicate, use tools when unsure, and lastly, ask the patient questions to retrieve information vital in providing the best patient outcomes.


            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

Bramhall, Elaine. Nursing Standard (2014+); London Vol. 29, Iss. 14, (Dec 3, 2014): 53. DOI:10.7748/ns.29.14.53. e9355

The Joint Commission, Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications, August 2012, Volume 32, Issue 8, 2019.

Shulman HB, Gilbert BC, Lansky A. The Pregnancy Risk Assessment Monitoring System (PRAMS): Current Methods and Evaluation of 2001 Response Rates. Public Health Reports. 2006;121(1):74-83.


Discussion: Building a Health History

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.

sample response 1

xxx, thank you for your post. I enjoyed reading your approach, which I found very compassionate and professional. Your approach for communication is also therapeutic. Having a healthy understanding of cultural diversity is important, and it is something that health providers will encounter. (Goodkind et al., 2011) reports that Native Americans have found distrust by European-American service providers, educators, and researchers who have intentionally or inadvertently imposed their values, beliefs, and systems of care upon individuals, families, and communities.

In this particular case, I would recommend inquiring about holistic or herbal medicinal approaches she may use. Herbal remedies have increasingly become the first choice for many American households as individuals are becoming more health conscious. (Illamola et al., 2020) talks about how many cultures have used herbal medicine (HM) in pregnancy to improve the wellbeing of the mother and/or baby, to help decrease nausea and vomiting, and prepare for labor because there is an assumption that HM is safer than conventional medicine.


Goodkind, J. R., Ross-Toledo, K., John, S., Hall, J., Ross, L., Freeland, L., Coletta, E., Becenti-Fundark, T., Poola, C., Roanhorse, R., & Lee, C. (2011). Rebuilding trust: A community, multiagency, state, and university partnership to improve behavioral health care for american indian youth, their families, and communities. Journal of Community Psychology39(4), 452–477.

Illamola, S. M., Amaeze, O. U., Krepkova, L. V., Birnbaum, A. K., Karanam, A., Job, K. M., Bortnikova, V. V., Sherwin, C. M., & Enioutina, E. Y. (2020). Use of herbal medicine by pregnant women: What physicians need to know. Frontiers in Pharmacology10

sample response 2

Hello xxx, great post and very informative, I enjoyed reading it. I agree with you that clear information can make a big difference in a patient’s treatment.  Unclear communication can cause unsatisfactory patient outcomes due to inaccurate information passed. Inadequate communications are a major factor contributing to adverse events, well-designed discharge orders promote accurate communication and poor communication is a major root cause of medical errors and patient harm (Stewart & Snowden, 2021). Also evaluating patient understanding of the teaching by having the patient demonstrate or verbalize what has been taught can be an effective way of knowing a patient has the right information.

According to research while interviewing a patient, establish rapport with the interviewee, accept emotional responses without criticism, refrain from interrupting the interviewee, structure interview questions so that they are easily understood (Luizzo, 2019). When the interviewer establishes good rapport, the patient can open up and answer questions asked. When interrupting the patient while interviewing, the patient might forget what he/she was about to say.


Stewart, J., & Snowden, V. (2021). Promoting Communication and Safety Through Clear and Concise Discharge Orders. Journal for Nurse Practitioners17(7), 874–878.

Luizzo, A. (2019). Effective interview techniques. Journal of Healthcare Protection Management35(2), 110–117.

sample response 3

Thank you for emphasizing the use of effective communication skills during your interview process to obtain accurate patient information and history such as active listening, maintaining good eye contact, and use of open- ended questions (Arsith, 2017). As practitioners, the use of effective communication help to build a good patient relationship that helps to develop great plan of care (Ball et al., 2019).


Arsith, M., & Popa, D. (2017). General aspects on the communication between healthcare provider and patient. Acta Universitatis Danubius. Communicatio11(1), 83–90.

Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2019). Seidel’s guide to physical examination: An interprofessional approach (mosby’s guide to physical examination) (9th ed.). Mosby.