essentials of evidenced based writing
Building Patients Health History
A main information component of health risk assessments is the detailed collection of family health history information. This information is helpful in determining risk both for common chronic conditions and more rare diseases as well (Wu & Orlando, 2015). The interview process of obtaining a health history is important to the treatment process. Effective communication skills are needed to build a trusting relationship with the patient. The patient should feel comfortable that they chose the right provider. The patient could seek care elsewhere if they immediately feel uncomfortable or apprehensive. Effective communication is built on courtesy, confirmation, connection, and comfort (Ball et al., 2015).
Interview and Communication Techniques
A 76-year-old Black/African-American male with disabilities in an urban setting will be utilized in the example for this discussion. The patient will first be greeted respectfully by knocking before entering the room and addressing him by Mr.… Privacy will be maintained and the patient’s privacy and modesty will be respected. He will be allowed enough time to fully answer the questions. Eye contact will be maintained and lament terms will be used. Open-ended questions will be used to facilitate the process. At the end of the visit the patient will be asked if there is anything further he would like to discuss and time will be allowed to verify the patients understanding of the plan of care.
Formal language is a sign of respect, especially to the elderly patient. Allowing the patient time to give his response will enable him to be correct and complete. Avoiding medical terminology will ensure he understands his medical treatment (U.S. Department of Health and Human Services, 2016).
Risk Assessment
Health risk assessments provide an opportunity to emphasize health promotion and disease prevention for individuals and populations at large (Wu & Orlando, 2015). In older persons with a relatively good prognosis, geriatric screening tools are of limited use in identifying persons at risk for decline in functional status or quality of life after one year. Hence, a geriatric screening tool cannot be relied on in isolation, but they do provide very valuable information and may prompt physicians to also consider different aspects of functioning (Deckx et al., 2015).
Other Assessment Tools
By completing the HRA, the clinician can identify patient’s needs, and further complete specific assessments based on the needs or problems identified. To identify the patient’s functional status, and areas of assistance needed with Activities of Daily Living (ADLs), the Needs Assessment Questionnaire and Task/Hour Guide (Form H2060) or the Community First Choice Assessment (Form H6516), which includes patient’s social supports, and person-centered questions that will individualize patient’s care (Texas Department of Health and Human Services, 2015).
Target Questions
Assessing the patients functional ability can assist with the care provided to the patient. The patient’s autonomy and independence is important for management and the healing process (Ball et al., 2015).
Target questions for this patient include:
- Do you have any difficulties walking around your home?
- Do you have any balance problems when you get up?
- Do you have difficulties grasping small objects or opening jars?
- Do you have difficulties with vacuuming, dusting, or mopping?
- Do you have difficulties grocery shopping or cooking?
- Do you have difficulties bathing, dressing, or using the toilet/commode?
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C., … & 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), 30.
U.S. Department of Health and Human Services. (2016). National Institute of Aging: Health and Aging. Retrieved from https://www.nia.nih.gov/health/publication/talking-your-older-patient/understanding-older-patients
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family
health history: barriers and benefits. Postgraduate medical journal, postgradmedj-2014.
