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Consider performing a health history on someone that may not be able to provide you with answers, such as an infant, child, an elderly person, a developmentally disabled individual, or patients who speak a language you do not know.
What strategies would you employ to obtain a complete health history?
Provide a rationale for why you think these strategies would be effective.
Sample Answer
When taking a health history for a patient who cannot communicate directly, such as a child or someone with a language barrier, a nurse must use a combination of indirect strategies to gather comprehensive information. A key approach is relying on an authorized and knowledgeable informant, such as a parent, legal guardian, or a caregiver.
Strategies for a Complete Health History
Use a Qualified Interpreter or Translator: For patients with a language barrier, utilizing a professional medical interpreter is crucial. Unlike a family member who may inadvertently omit or misinterpret information, a qualified interpreter ensures accurate, confidential, and culturally sensitive communication. This is vital for obtaining a detailed history of present illness, past medical history, and social context. The use of a professional service minimizes the risk of medical errors that could arise from mistranslation.
Employ Open-Ended and Targeted Questions to the Informant: Instead of simple yes/no questions, ask open-ended questions like, "Can you describe what happened when the cough started?" This encourages the informant to provide a more detailed narrative. For specific information, use targeted questions, for example, "Has the child had all their vaccinations?"
Incorporate Observational Assessment: When working with an infant or a non-verbal patient, a significant part of the health history comes from direct observation. A nurse should carefully observe the patient's physical appearance, behavior, and interaction with their caregiver. For example, is the child alert and playful, or lethargic and irritable? Are there signs of distress or pain? Observation provides critical context that cannot be verbally communicated.
Review Medical Records and Documents: Prior to the appointment, review any available medical records, including immunization cards, hospital discharge summaries, or records from other specialists. This provides a baseline of past diagnoses, allergies, and treatments. A review of these documents helps fill in gaps and validates the information provided by the informant.
Rationale for Effectiveness
These strategies are effective because they shift the focus from a single, verbal source of information to a multi-faceted approach. Relying on a professional interpreter and knowledgeable informant ensures the accuracy and completeness of the history, while observation and record review corroborate and expand upon the verbal information. This holistic method ensures all aspects of the patient's health are considered, leading to a more accurate diagnosis and a safer, more effective care plan. A study in the Journal of General Internal Medicine (2020) found that professional interpreters significantly improve communication and clinical outcomes for patients with limited English proficiency.