This health history focuses on a 76-year-old African-American male with disabilities living in an urban setting. For this patient, it is especially important to pay attention to his age, disability, and ethnicity. It is appropriate to interview the patient as an integral part of communication between the patient and the caregiver. According to Ball, Dains, Flynn, Solomon, and Stewart (2015), “establishing a positive patient relationship depends on communication built on courtesy, comfort, connection, and confirmation” (p. 2).
Therefore, the interview would be conducted in a comfortable exam room to ensure proper accommodation with his disability. The introduction of a clinician would be followed by the explanation of privacy terms, identification of the patient’s name, and then by open-ended questions regarding his physical and psychological state and health issues. The patient-centered approach would be used to gather more data and help the patient timely.
The Home Safety Self-Assessment Tool (HSSAT) would be applied to evaluate the patient’s living conditions in terms of safety (fall prevention) and quality (the presence of accessible features). The functional assessment would also be used to determine the ability of the patient to care about himself and what level of care is needed (Bickley & Szilagyi, 2012). This would help to select relevant interventions.
More to the point, multi-assessment may be important for older patients who have several health problems and need different types of assistance, including mental health, disability, and physical issues (Weber & Kelley, 2014). The received data should be documented in the first-person narrative to properly reflect the patient’s state and feelings (Sullivan, 2012). The following questions are to be asked:
- How do you feel about your disease?
- Do you live alone or have someone to care about you?
- How do you cope with your illness? Do you get aggressive or depressed?
- What quality of life do you want to achieve? How do you understand it?
- What is your previous health history? Note any hospitalizations or complications.
- Have you fallen recently?
In addition, some other detailing questions should also be posed to ensure that all required data is collected to build the health history. The potential health-related risks for the given patient are associated with falls, inability to access some home features, age-related disease such as dementia or fragility of bones, and ethnicity-based discrimination in health care settings. As stated by Côté, Crocker, Nicholls, and Seto (2012), the Historical-Clinical-Risk Management-20 (HCR-20) instrument is a comprehensive tool to determine potential violence risks, focusing on threat evaluation in clinical practice. Another option is a comprehensive health assessment that identifies the past and current health state of the patient (Forbes & Watt, 2016).
It would be applicable to the selected patient due to his age and disability, which require precise attention from a clinician who is expected to create a complete health risk assessment, thus eliminating potential health threats. The paramount goal of a clinician during the interview with this patient is to adapt to his needs and respond professionally to his health concerns.
In sum, the identified patient is to be examined in a comfortable setting and friendly atmosphere. The role of a clinician is to act as an adviser and encourage the patient to express his health problems, concerns, and suggestions. HSSAT, HCR-20, and comprehensive risk evaluation tool would be used to collect necessary information and assist the patient. Honesty, transparency, privacy, and respect are the key concepts that should be used during the examination.
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.
Bickley, L., & Szilagyi, P. G. (2012). Bates’ guide to physical examination and history-taking (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Côté, G., Crocker, A. G., Nicholls, T. L., & Seto, M. C. (2012). Risk assessment instruments in clinical practice. The Canadian Journal of Psychiatry, 57(4), 238-244.
Forbes, H., & Watt, E. (2016). Jarvis’s physical examination and health assessment (2nd ed.). Chatswood, Australia: Elsevier Health Sciences.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Weber, J. R., & Kelley, J. H. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.