please respond tomelanie shelly wk 1 discussion post H e a l t h M e d i c a l

please respond tomelanie shelly wk 1 discussion post H e a l t h M e d i c a l

Please respond to

Melanie Shelly

Wk 1 Discussion Post- Melanie Shelly


Building a Health History

Building a health history not only allows you, the advanced practitioner, to get to know vital health related information about your patient, but it also is a key component in the formation of trust, the foundation of a strong

patient-provider relationship (Ball et al., 2019). A health history includes patient identifiers (i.e. name, date of birth and gender), chief complaint or concern, a history of the present illness or issue, past medical history, family

history, social history, and finally, a complete review of body systems (2019, p.6). Common potential barriers to communication such as anxiety, fear, depression and anger can inhibit attempts to build upon or develop a health

history with a patient (2019). As healthcare practitioners, it is important to also recognize cultural differences as potential barriers to communication, treatment and health outcomes (Polster, 2018).When attempting to build a

relationship with a patient from a foreign country or of different cultural beliefs, communication and teaching techniques may need to be altered to enhance the patients understanding and overall comfortability.

New Patient Scenario

A 40-year-old, black, recent immigrant woman from Africa comes into the practice to be evaluated and treated. She currently does not have health insurance. Due to this patient’s lack of insurance, accessibility to healthcare may

be extremely limited (Sullivan, 2019). Prior to obtaining patient history, it may be wise to discuss health care treatment options for the uninsured, such as prescribing generic medications, if medications become necessary (2019).

The conversation can be kept simple until after more health-related information is obtained to further guide the dialogue as necessary.

For this particular patient, you may find benefit in focusing more time initially with her social history. Gathering this information first will allow you as the provider to determine how her cultural beliefs and practices may impact

communication, her beliefs about health and specific treatments as well as dietary preferences and familial or community relationships she has developed (Ball et al., 2019). Once any language barriers are addressed if necessary,

a good initial question may be, “I would like to respect your cultural values and beliefs, in doing so, what do I need to know to best provide you care?” (2019, p.13). When discussing her reason for seeking care, we must also

consider her age, discussing preventative care measures, but also her immigration status, reviewing her immunization history and determine any risk of infectious disease exposure. Additional questions may include, what do you

think has caused this issue or illness? Have you used any home remedies to try and treat this? Would you consider taking prescription medication? Would you prefer the use of alternative treatments such as herbal remedies?

(Sullivan, 2019, p.27). Providing culturally competent care not only enhances the patient experience, but it also improves healthcare provider communication (Polster, 2018, p.33).

In conclusion, the length of time spent with this new patient may have to be adjusted in order to address her cultural beliefs and practices. It is imperative to show respect not only to her as a patient but also to these customs,

this will not only strengthen the foundation of this relationship, but it may also provide necessary insight to her chief complaint. Her lack of insurance may be problematic, especially in terms of preventative screenings such as a

mammogram or blood work, however resources may be available for discounted or free services or community clinics. Although there is a heavy focus on this patient’s social history, the addition of her past medical history,

family history and review of systems should present a clear clinical picture.


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.). Elsevier.

Polster, D. S. (2018). Confronting barriers to improve healthcare literacy and cultural competency in disparate populations. Nursing2018, 48(12), 29–33.….

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis .

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