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Building a health history with a new patient requires more than active listening and the development of trust and rapport. The intake interview and initial health assessment should be thorough, taking into account the area(s) in which the patient has lived, their workplace environment or work history, their family background and family health history, socioeconomic variables, and any other relevant environmental factors that may impact personal health. Of course, demographic variables like age, ethnicity, and gender will all be taken into account when building a health history with a new patient. Communication techniques and interviewing style, risk assessment instruments, and the specific questions to be asked would also vary considerably depending on the patient. Consider the following example of a pre-school aged white female living in a rural community:
A pre-school aged white female needs to be interviewed with a parent or legal guardian present for practical, legal, and ethical purposes (Goetzel, Staley, Ogden, et al, 2011). In fact, the majority of the interview questions would be directed at the adult because the pre-school aged patient will be unable to respond to some of the more in-depth inquiries due to a lack of health literacy (“Health Risk Assessments,”...
The interview process can be used as a springboard for building health literacy in the young patient, but the parent or guardian remains responsible for answering the questions related to health risks, environmental variables, family or cultural background, and any other relevant variable. In some ways, having the parent or guardian present helps the nurse build a more comprehensive patient health history than with a patient who is of the age of majority because the family member can fill in some of the pertinent details or add information the patient might leave out. Five targeted questions I would present to the patient and the present parent or guardian are as follows:
1. (Directed to the parent/guardian): Do you or the biological parents have a history of any disease or medical condition, such as heart disease, diabetes, or cancer?
2. (Directed at the patient): How are you feeling? Do you ever feel any pain or discomfort? If so, when? When directing questions at the young patient, it is important to pay attention to the reaction and assess their level of health literacy or understanding or engagement.
3. (Directed to the parent/guardian): You live in a rural area. What medical or healthcare services…
References
Goetzel, R.Z., Staley, P., Ogden, L, et al. (2011). A framework for patient-centered health risk assessments. CDC. https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf
“Health Risk Assessments,” (n.d.). Stratis Health. https://www.stratishealth.org/documents/HITToolkitcoordination/4-Health-Risk-Assessments.pdf
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