Health History Interview Overview
These kinds of interviews are mainly concerned with getting important information from the patient concerning their health. The information is subjective. It is important to foster a good relationship with the patient from the onset (Estes 2010). At the end of the interview it would be important to give the patient some information that will enable him to get a better understanding of their medical condition. Making wrong findings may be dangerous.
The health history interviews seek to serve some of the following purposes: get information from the patient to help in the diagnosis, which serves as a perfect avenue for creating a good relationship between nurses and patients; and lastly to obtain data concerning various support systems (Barkauskas, Baumann & Fisher 2002). The reason for this is that nurses are the first people that patients have contact with when they visit health facilities.
The place where to conduct the interview was a major challenge due to the fact that the interview would take some time. An outpatient health care facility would therefore be inappropriate for this kind of interview. I was also looking for a health facility that treats or specializes in respiratory diseases as this would be my topic for the interview.
It was also important to find a place where there would be minimal disturbance. The interview would take some time and if there were to be distractions it would even take longer. It was also important for me to find a place that was private. The interview would involve the patient talking about their health history and discretion should be upheld during this type of discussions.
Before conducting the interview, I familiarized myself with the medical condition of the patient. I also made sure I had all the material needed to conduct the interview. It is also worth notifying the patient about the type of interview and what would be expected from them (Barkauskas et al. 2002). I notified the patient that he should provide truthful information that would help us understand his condition better. This would also help in the diagnosis of the condition.
Quality of documentation
It is important to keep proper documentation. This can be done by making sure one observes some simple regulations that would make the documentation process easier. Having a pen and paper are the basics of quality documentation.
My recordings were to be clear, accurate, complete and concise. I also had to use nursing terms in recording the information. I also had to make sure I did not duplicate the information already given. To make sure that I did not leave out any information, I had to employ both subjective and objective data collection methods. However, while collecting objective data, it was hard not being biased and only record what was true while also trying to avoid stereotyping (Barkauskas et al. 2002).
In order to collect and record relevant information I decided that I would paraphrase the information given to me by the patient or in extreme cases quote him directly. It was important to not only record the findings but to include all the relevant details as well (Newell 1994). I had to take time and describe my findings more accurately. I had to make sure I express myself in a way that anyone reading my assessment would clearly understand the facts and would not be mislead.
Accuracy of diagnostic judgement
It is important to find out the accuracy of the findings after each and every interview. This will go a long way in ensuring that you do not give false or misleading information. I had to make sure that my findings went hand in hand with what the doctor had already found.
I also had to go through my findings to determine whether I had recorded all the relevant information I had intended to have. To do this effectively, I intentionally repeated some questions asked at the beginning of the interview. Then I made sure that the responses were alike. If they are alike – the information is accurate. In case of a sensitive question I restructured the question.
This is done just as a measure of the accuracy of the data you have just collected. Once I had collected the data, I had to critically look into it. One might find errors and that may raise your attention. This is also done to make sure that the information is consistent (Standing 2012).
I took all the accuracy assessment measures listed above and concluded that the findings I had collected were accurate and consistent. My respondent had been truthful. This ensured that I had minimized anomalies in my findings. However, there had been a slight inconsistency, but I got to the root of the matter and solved the anomaly.
Assessment outcome statements
It is these findings that would help us to come up with a proper diagnosis for the patient. Judgement made should be consistent with the findings that are obtained during the actual interview. The North America Diagnosis Association (N.A.D.A) has come up with a list of diagnoses (Weber 2008). This will help arrive at the assessment much easier after looking at the patient’s health history.
After carefully studying my findings and employing medical knowledge, a medical practitioner could comfortably come to the conclusion that the patient was suffering from a respiratory disorder.
Humanness of the assessment
I took the patient’s complaints with the seriousness it deserved. I took time to understand the fact that patients differ and that every case should be handled with care while maintaining a personal touch. I tried to put the interests of the patient first at all times during the interview.
I tried to be humane and address some of the negative perceptions the patient had. The patient had lost hope in the medication he was receiving. As a result, he did not believe that he would ever get well. I intervened and explained that the medication will take time before producing an effect on his body. The rate at which the medication might be working was slow and it was only by following instructions from the doctor and taking the medication, that he will be well again.
Interview techniques applied
This is the most important part of the interview. It would determine the amount of information I get and also have a direct effect on my findings. I took this part of the interview very seriously (Carlson 1997). It was important that I employ all the interview techniques at my disposal. This would help me get more information from the interview. That said, I also had to evaluate on the different interviewing techniques that would be best suited for this interview.
Open ended questions
These are the questions that came to my mind relevant to the situation that would help me understand the health history of the patient. These questions have no specific answers and would give the patient more space to elaborate on his answers. This, however, turned to be time consuming (Weber 2008). I also had to make the interview interesting, so that the patient would not feel bored or get tired of the question answer session.
There were instances during the interview that the patient did not give accurate answers. However, I could take note of his physical behaviour. While employing this method I had to make sure that I would not be judgmental or imply stereotypes towards the patient. The patient kept sending non-verbal information that I would notice from time to time during the interview.
Close ended questions
These are the questions that have a yes or no answer. They are very important in getting to know about the health history of the patient. They are specific and hit the nail on the head making findings more accurate.
It was important to look into the eyes of the patient. This would maintain a personal relationship during the period of the interview (Bellack & Edlund 1992). By looking into the eyes of the patient and maintaining an eye contact, I was able to read his feelings. This helps to identify the questions he was not comfortable with. The patient was not comfortable with some of my questions. I was, however, able to change the format of the questions and in the end got the answers I needed.
It is important to conduct these interviews. They help the care givers to be in a position to know about the issues their patients are facing. Health history is also important, to get to know about the patient in a medical way. This helps to keep good statistics and demographic information which can be used in the future.
Barkauskas, V., Baumann, L. C., & Fisher, C. S. (2002). Health and physical assessment. St. Louis, MO: Mosby.
Bellack, J. P., & Edlund, B. (1992). Nursing assessment and diagnosis. Boston: Jones & Bartlett.
Carlson, J. H. (1997). Nursing diagnosis: a case study approach. Philadelphia: Saunders.
Estes, M. E. (2010). Health assessment & physical examination. Clifton Park, NY: Delmar, Cengage Learning.
Newell, R. (1994). Interviewing skills for nurses and other health care professionals: a structured approach. London: Routledge.
Standing, M. (2012).Patient assessment and care planning in nursing. London: Learning Matters.
Weber, J. (2008). Nurses’ handbook of health assessment. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.