Assignment: Building a Health History Summary Paper

Assignment: Building a Health History Summary Paper

Assignment Building a Health History Summary Paper

By establishing a good rapport with your patient, you could effectively gather important health information from him, which enabled you to identify and educate your patient about potential health-related risks. Your communication techniques allowed your patient to open up and share more pertinent information essential for his care. You actively listened to your patient and were non-judgmental.

At all times, to keep your patient comfortable, you were aware of your facial expressions, where you sat,  the distance from your patient, your nonverbal cues which complemented your listening, the manner you asked the questions, and how often you looked at your computer to take notes. That showed you were really present in the room, open and engaged with the patient leading to a trust-enhancing or even therapeutic exchange (Ball et al. 2019).

You knew that discussing sexually transmitted diseases (STDs) was a sensitive topic for an adolescent patient; you addressed the subject respectfully while offering constant help and support to your patient. You maintained the patient’s privacy and were willing to ask his parents (if they were with him) to leave the room, prioritizing your patient preference and autonomy to engage him in his care.

You educated your adolescent patient about safe sex at his education level; you purposefully avoided the utilization of medical jargon and utilized words that your patient was able to understand to avoid confusion and anxiety. You explained to your patient that you were asking him very personal questions to identify risks, to allow him to discuss his concerns, and to create his care plan (Ball et al., 2019).

Summarizing and clarifying what you have discussed with your patients are perfect ways of confirming the patient’s understanding, alleviating the patient’s fear, and, with further exploration helping the patient voice his concerns (Ball et al., 2019). This will engage the patient to participate in his plan of care. The 5 P’s of sexual history is a very good approach that allows you to discuss important areas with your patient.  Your targeted questions were open-ended.

I would have asked the patient for his sexual orientation and his gender to

appropriately continue to offer care to him (Ball et al., 2019). I would ask if he is still sexually active. In what way?  What is the frequency of his intercourse? These questions help “Identify risk factors for unintentional pregnancy and sexually transmitted infections (STIs) as an important part of the sexual history” (Ball et al., 2019, p.11). I would have mentioned to the patient that I would have an extra care worker or chaperone in the room during the (intimate) exam.

“A chaperone is encouraged to be present in any medical consultation, especially when an intimate examination is required. This impartial attendant could reassure the patient, especially when gender is an issue, and may avoid conflicts in the patient-physician relationship. Situations where a chaperone is unavailable or is declined by the patient present special ethical problems and may impinge on an appropriate therapeutic relationship, the patient-physician relationship” (Chandramani et al., 2017).

Thank you for your educational post.

References

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

Chandramani, T., Sivalingam, N. & Davendralingam, S. (2017). The Chaperone in a therapeutic relationship: A

critical discussion. International Journal of Person-Centered Medicine, 7(1), 53-60.

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Question Description

I need help with a Health & Medical question. All explanations and answers will be used to help me learn.

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.

This is my patient: 76-year-old black male with disabilities living in an urban setting

This it the risk assessment instrument- POMR (Problem-Oriented Medical Record)

1. Comprehensive health history
2. Complete physical examination
3. Problem list
4. Assessment and plan
5. Baseline and problem-directed laboratory and radiologic imaging studies

6. Progress notes

APA format- 3 sources cited. Interview style, relevant questions pertaining to the patient.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.