A Guide to Taking a Patient's Health History Essay

Increased public demand to access health information and growth of consumerism in health care industry are two important reasons form increasing attention to Personal Health Records (PHRs) in the recent years. Surveys show that a considerable number of people want to have access to their health information. In one survey, 60 percent of respondents wanted physicians to provide online access to medical records and test results, and online appointment scheduling; 1 in 4 said they would pay more for the service.

4.) double check you have the correct patient by having them say their name ,date of birth and possibly other basic information to prevent reveal of private health information

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

A. Identify appropriate history questions to be asked of the patient, nursing staff, or family in order to discriminate critical characteristics or attributes about the presenting problem.

I was able to gather a lot of information on my patient when I was taking his health history, giving his shift assessment, and reviewing his charts. I used this step to offer effective nursing care to determine the priorities of what is the most important issue for which the patient should be treated.

Using this example, we clearly see that the nurse asks the patient a direct and clear question so as to get information and in turn she gets a response. It is suggested that this is a good example of questioning and probing and it is recommended to be used again in future. To provide the most effective care possible, nurses must begin with clear and appropriate verbal skills such as being honest, being concise and keeping emotions out of the conversation (Apler, 2006).

The first phase of the nursing process is the assessment of the current needs/problems presented upon Mr. Smith’s arrival to hospital. The initial assessment requires the nurse to gain consent in order to gather any information such as his contact details as well as the contact details of his next of kin who in this case his is wife Susan and also the details of his GP, any known allergies he may have and any medications he may currently be on, whether he has dentures as well as his weight and BMI. During this phase, communication with the patient and family is essential to ensure that correct information is obtained so that a proper informed decision concerning his care can be made. In this case there may be some barriers that may effect the assessment process and that is the speech of Mr. smith is sometimes slurred, therefore he may need his wife to answer some of the more complex questions that require more than a yes or no answer. Nurses need to choose their words carefully so that they match the patient’s ability to understand them avoiding the use of medical jargon (Kraszewski & McEwen 2010). The dignity of the patient must be maintained at all times through all phases of the nursing process and a comfortable environment is essential-preferably in a private room or if not ensuring that the curtain is drawn out of respect for the patient (Barnes

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.

In this assignment I will be exploring the issues around communication and assessment in relation to the care given to the patient. I will look at how care was delivered and how successful it was. The NMC (2008) states that healthcare professionals must respect a person’s right to confidentiality; to ensure this I will be using pseudonyms for the service users mentioned in this assignment. I will be referring to the patient as ‘John’ and his wife as ‘Brenda’. I have gained consent from Brenda to talk about her husband’s situation in this assignment, as he did not have capacity to grant consent himself due to dementia.

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.

According to Healthy People 2012 there are more then 800,000 new cases of diabetes each year, with the numbers on the rise. With this in mind, Healthy People 2012 has identified diabetes as their number five focus area. In order to reach their goal of improving the quality of life for people with diabetes they have identified diabetes teaching as their number one objective. Furthermore, in order to reduce the number of complications of diabetes, Healthy People 2012 has identified foot ulcers as their ninth objective. Through patient education Healthy People 2012 hopes to reduce the number of foot ulcers in people with diabetes, as diabetes is the number one cause of nontraumatic amputations in the United States. In order to

A twist on the "patient's perspective" approach is to describe a time when medicine failed to save or heal someone close to you. The purpose of this tactic would not of course be to rail against the medical profession, but rather to show how a disappointing loss inspired you to join the struggle against disease and sickness.

I have personally been affected by the mess that America calls a health system. In the same year, I had severe food poisoning and my stomach and intestines swelled. I had to be hospitalized for a day each, and was then sent home, even though I was still very ill. The reason? My family has no health coverage. Both my parents are very hard workers and own their own business. One would think that my household could afford health coverage, but we can't, despite the many hours a week and hard labor. So, without coverage, there are heavy bills to pay. My mom and I have calculated that my parents will be paying hospital bills long after I graduate from college. Because of two days in the hospital, six bags of saline, and a bagel from the

Let children be children, is not only a popular phrase heard in education, but it is also my motto. Yes, it is true, today’s children are tomorrow’s future; but how we choose to raise our children determines the outcome of our future. Many believe academics should be stressed more in schools, taking away from children’s playtime. I feel that play is what molds a child. Play allows not only a child’s imagination to run freely, but builds and strengthens children’s motor, language, cognitive, and social emotional development skills. I believe that play; along with parental involvement forms a child’s identity. Play is what makes children: tomorrow’s future.