NURS 6512 Building a Comprehensive Health History Paper

NURS 6512 Building a Comprehensive Health History Paper

Upon establishing a relationship and building a comprehensive health history, one must understand the importance of a thorough history document.  This document is often used as the basis for the entire course of medical management for a patient (Sullivan, 2012).  Everyone has a story, and the heath history document should paint an up-to-date and accurate account of the patient’s medical history and a comprehensive physical examination.  Any professional that reads the health history document should have a good overview of that patient.  

NURS 6512 Building a Comprehensive Health History Paper

According to Ball, Dains, Flynn, Solomon, & Stewart (2015), the initial meeting between the clinician and the patient sets the tone in the relationship for success, allows the patient to voice concerns, identifies expectations for a good outcome, and to build a partnership in one’s health care.   For this week’s discussion, the role of a clinician when building a comprehensive health history with a 16-year old white pregnant teenager living in an inner- city neighborhood will be identified.  In addition, review of communication techniques and a risk assessment tool is used with five or more targeted questions that could be asked in this particular situation.


Interview and Communication Techniques

Adolescents is a time between childhood and adulthood where risky behaviors are experimented and where privacy and confidentiality are important to be less hesitant in discussing their concerns (Ball,, 2015).  Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents with confidentiality (Ham, & Allen, 2012).  

According to Thompson (2010), obtaining a necessary ‘social history’ of each teenager can help to gain vital information about their relationships, assess the needs of the individual, and identify possible problems throughout the pregnancy.  There are a number of issues relevant to teenage parents, such as; age, emotional maturity, relationship with parents/partner, educational needs, looked after children, social situation, and supporting young fathers-to-be (Thompson, 2010).  The social history is a series of detailed questions creating the basis of the assessment and care plan.  The care plan and assessment information is updated throughout the pregnancy and the plan is altered as the situation demands (Thompson, 2010).

Questions should be open-ended so that feedback is prompted, yet, declining to answer should be acceptable as well (Ball,, 2015).  For questions that are answered, further investigation can be encouraged to continue the evaluation of the situation.  In addition, a screening tool or questionnaire at the pre-visit stage can also encourage a non-forced conversation by silently writing the concern rather than verbalizing the concern (Ball,, 2015).  

Questions should pertain to thorough evaluation of her partner(s), sexually transmitted infection (STI) history, last menstrual cycle, medical history, previous gynecological visits, social/personal history (including current/previous smoking, drug or alcohol use), family history, and current outlook on the pregnancy.  A time for the patient to ask any questions or express any concerns should be followed up, so that the patient is still involved and can feel in control and knowledgeable of the situation.  A full head to toe assessment should be completed, including fetal heart tones.  The patient-provider relationship should be respectful, useful, and effective with honest responses, making good eye contact, and maintaining non-judgmental respect of wishes.

Risk Assessment Instruments

As above, obtaining a social history can not only assess risky behaviors, discussing general social behaviors can also help to open the door to a better patient-provider relationship. The use of the screening tools HEEADSSS and PACES can guide adolescent issues such as sex, drugs, smoking, alcohol, peer pressure, home environment, and school (Ball, et al., 2015).  The answers to these questions can help the provider obtain the knowledge and readiness of the patient’s needs for further educational needs and assistance from the provider (Ball, et al., 2015).

Health-Related Risk Potential

Other situations may arise that can be detrimental health concerns for the patient and the unborn child.  Due to age, teenagers are at risk for not obtaining adequate prenatal care.  This screens for medical problems in both mother and baby, monitors the baby’s growth, and deals quickly with any complications that arise.  Prenatal vitamins with folic acid (ideally taken before getting pregnant) are essential to help prevent certain birth defects, such as neural tube defects (CDC, 2010).

Pregnant teens have a higher risk of getting high blood pressure (pregnancy-induced hypertension) than pregnant women in their 20s or 30s (CDC, 2010, NURS 6512 Building a Comprehensive Health History Paper).  They also have a higher risk of preeclampsia, which is a dangerous medical condition that combines high blood pressure with excess protein in the urine, swelling of a mother’s hands and face, and organ damage (CDC, 2010).  In addition, pregnant teens may be at higher risk of postpartum depression (CDC, 2010).

Target Questions

Several target questions may be used to help determine risks and build an up-to-date accurate health history.  These questions may also help to obtain sexual history, any violence or potential violence, family support, and any other potential high risk endeavors that may harm the fetus or the patient.  The questions below may be asked in a different sequence depending on the conversation and situation.

  1. When was your last menstrual cycle?
  2. Was this a planned pregnancy?
  3. Have you had any previous pregnancies?
  4. What is your current outlook on this pregnancy?
  5. How many sex partners have you had?
  6. Do you drink alcohol, smoke, or do recreational drugs? If so, how often?
  7. Do you have a good relationship with your parents?
  8. Have you ever been ‘in care’ or a ‘looked after child’?
  9. How does your parents feel about you being pregnant?
  10. Do you think your parents will support you?
  11. How are you doing in school?
  12. Do you have any questions for me?


Encouragement and education can go a long way with a teenager who is pregnant.  A practitioner that can listen and treat to the best of their ability without judgement is one who has built a relationship on trust, honesty, and respect with the patient, no matter the age or circumstance.  Thus, obtaining a health history that is accurate and reflects the patient’s situation, identifying the possible risk factors or complications that could arise.

References for NURS 6512 Building a Comprehensive Health History Paper

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.

Center for Disease Control and Prevention (CDC). (2010). Reproductive Health: Teen Pregnancy. Retrieved from:

Ham, P., & Allen, C. (2012). Adolescent health screening and counseling. American Family Physician, 86(12), 1109-1116.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

Thompson, S. (2010). The complexities of supporting teenagers in pregnancy. British Journal Of Midwifery, 18(6), 368-372.

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

NURS 6512 Building a Comprehensive Health History Paper 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. 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. 

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

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from

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)

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!

Building a Health History Discussion Example

The discussion highlights the importance of comprehensive data collection and effective communication in treating a 19-year-old black male athlete experiencing muscle pain. The discussion acknowledges the significance of establishing a rapport with the patient, particularly in the case of adolescents and young adults. According to Molina and Gallo (2020), creating a comfortable environment encourages patients to openly express their experiences and provide valuable subjective and objective information.

The discussion also emphasizes using adaptive questioning and active listening as effective techniques to allow patients to communicate their concerns without interruption. I would apply effective communication and interview techniques to establish a rapport and gather comprehensive information. I would introduce myself, explain the purpose of the interview, and ensure the patient’s privacy and confidentiality. I would use open-ended questions to encourage patients to provide detailed responses and share their concerns regarding muscle pain.

Active listening skills would be essential to demonstrate empathy and understanding and encourage patients to express themselves fully. Byrne et al. (2020) assert that a patient-centered approach creates a comfortable and non-judgmental environment, allowing the patient to freely express their symptoms, concerns, and any relevant contextual information. I would use non-verbal cues such as maintaining eye contact, nodding, and appropriate body language to convey attentiveness and interest.

Assessment Tool

The OPQRST mnemonic would be the most suitable assessment tool to assess the patient’s health risks related to muscle pain. This tool explores various aspects of the pain experience, including the onset, palliative and provocative factors, quality, region and radiation, severity, and timing of the pain (Ford, 2019).

O – Onset: Determine when the pain started and what was happening then. Understanding the circumstances surrounding the onset of pain can provide insight into potential causes or triggers.

P – Palliative and Provocative factors: Identity what makes the pain better or worse. Inquire about specific activities, positions, or treatments that alleviate or aggravate the pain. This information can help identify contributing factors.

Q – Quality: Describe the pain. Is it burning, sharp, shooting, aching, throbbing, or another sensation? Understanding the characteristics and nature of the pain can assist in narrowing down potential causes and guide further assessment.

R – Region and Radiation: Determine the precise location of the pain and whether it spreads to other areas. Identifying the specific region and associated radiation can help identify potential underlying structures or systems affected.

S – Severity: Assess the pain intensity using a scale such as the functional pain scale or numeric rating scale (NRS). This will help determine how severe the pain is and how it impacts the patient’s ability to engage in daily activities.

Additionally, the functional pain scale and numeric rating scale (NRS) can be implemented to evaluate pain intensity on a scale of zero to ten and determine its impact on daily activities (Ford, 2019). These assessment tools facilitate a comprehensive understanding of the patient’s pain experience and functional limitations.

Factors Impacting the Health and Risk Assessment

Factors impacting this patient’s health and risk assessment are multifaceted and include the patient’s athletic status, ethnicity, environmental factors, age, gender, and the availability of healthcare resources. As an athlete on a scholarship, the patient may face an increased risk of sports-related injuries or overuse injuries, which could be contributing to the muscle pain he is experiencing. Furthermore, being a black male, the patient may be more susceptible to specific health conditions prevalent within their ethnic group, such as hypertension, which can contribute to muscle pain.

Environmental factors play a significant role in health risks as well. Exposure to extreme temperatures or inadequate training facilities can increase the risk of muscle pain or injury (Leyk, 2019). Additionally, the patient’s age is an essential factor to consider. As a 19-year-old, he may be more prone to musculoskeletal injuries or strains related to physical activities that are common in young adults. Gender can also impact health risks, with males potentially being at a higher risk for certain sports-related injuries or musculoskeletal conditions.

Finally, the patient’s access to healthcare, socioeconomic status, and community resources are crucial determinants of their health risks. According to the National Academies of Sciences (2019), limited access to healthcare or inadequate resources in their environment may hinder their ability to seek appropriate care for their muscle pain or address any underlying health conditions. Thus, a comprehensive data collection process is essential to assess all these factors and determine the best course of action for treating the patient effectively.

The Five Targeted Questions to Ask the Patient

  1. Can you describe the nature and location of your muscle pain?
  2. When did you first notice the muscle pain? Was there any specific event or activity associated with its onset?
  3. Have you experienced similar muscle pain in the past? If so, how did you manage or treat it?
  4. Are there any activities or movements that worsen or alleviate the muscle pain?
  5. Do you have any known medical conditions or a family history of musculoskeletal problems?

NURS 6512 Building a Comprehensive Health History Paper References

Byrne, A.-L., Baldwin, A., & Harvey, C. (2020). Whose center is it anyway? Defining person-centered care in nursing: An integrative review. PLOS ONE, 15(3).

Ford, C. (2019, April 11). British Journal of Nursing – adult pain assessment and Management. British Journal of Nursing.

Leyk, D. (2019). Health risks and interventions in exertional heat stress. Deutsches Aerzteblatt Online.

Molina, J., & Gallo, J. (2020). Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International Journal of Environmental Research and Public Health, 17(3), 835.

National Academies of Sciences. (2019). Factors that affect healthcare utilization. In National Academies Press (US).

Week 2 Case Studies

In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.

Also Read: NRNP 6645 Family Assessment And Psychotherapeutic Approaches Paper