Health Assessment Interview & Complete Health History: Study Notes for Personal Health

Health Assessment Interview

Goals of the Interview

The health assessment interview is a foundational process in personal health, aiming to collect comprehensive information about a patient's health status. The main goals are:

• Gathering Data: Collecting subjective (patient-reported) and objective (clinician-observed) information.

• Establishing Trust: Building rapport to encourage honest communication.

• Teaching: Providing health education during the interaction.

• Health Promotion & Disease Prevention: Discussing ways to improve health and prevent illness.

Components of the Interview

Effective interviews include several key components:

• Introduction: Briefly introduce yourself and your role.

• Purpose: Explain why the interview is being conducted.

• Time: Set expectations for the duration.

• Expectations: Clarify what will happen during the interview.

• Confidentiality: Assure privacy of information shared.

• Costs: Discuss any financial aspects if relevant.

Communication Types

Communication during the interview can be:

• Verbal: Spoken words, questions, and answers.

• Nonverbal: Body language, facial expressions, gestures, and tone of voice.

Important Factors for Interview

Several internal and external factors influence the quality of the interview:

• Internal Factors: Liking others, empathy, active listening, self-awareness.

• External Factors: Privacy, minimizing interruptions, comfortable environment, appropriate dress, note-taking, and use of electronic health records.

Setting up the Interview

To establish a professional environment:

• Keep introductions short and formal.

• Use surnames with adults and clarify name pronunciation.

• State your identity and role.

• Emphasize that this is not a social visit.

Techniques of Communication

Effective communication techniques include:

• Open-ended Questions: Encourage detailed responses and facilitate the start or change of topics.

• Closed or Directed Questions: Used when specific information or short answers are needed.

When to Use Open vs. Closed Questions

• Open-ended: Beginning of interview, topic changes, introducing new topics.

• Closed: When specific information is required, short answers, or to force a choice.

Assisting the Narrative/Therapeutic Communication

Therapeutic communication techniques help patients express themselves:

• Facilitation

• Silence

• Reflection

• Empathy

• Clarification

• Confrontation

• Interpretation

• Explanation

• Summary

Ten Traps to Interviewing

Avoid these common pitfalls:

• False assurance/reassurance

• Unwanted advice

• Using authority

• Avoidance language

• Distancing

• Professional jargon

• Leading or biased questions

• Talking too much

• Interrupting

• "Why" questions

Nonverbal Skills

Nonverbal communication is crucial in health interviews:

• Physical appearance

• Posture

• Gestures

• Facial expressions

• Eye contact

• Voice

• Touch

Closure of the Interview

End the interview smoothly:

• Ease into closure

• Thank the patient for their cooperation

Special Situations

Adapt interview techniques for special populations:

• Developmental stages

• Hearing impaired

• Acutely ill

• Impaired communication

• Personal or emotional displays

• Sexually aggressive behavior

• Threats of violence

• Cultural considerations

• Touch sensitivity

Interpreters

Interpreters are mandated by law for patients with language barriers. Use professional interpreters, not family members, and always address the client directly.

Complete Health History

Components of Health History

A complete health history includes:

• Biographic Data: Basic demographic information.

• Source of History: Who provides the information.

• Reason for Seeking Care (Chief Complaint): Main health concern.

• Present Health History/Illness (HPI): Details of current issue.

• Past History: Previous illnesses, surgeries, hospitalizations.

• Medication Reconciliation: Current and past medications.

• Family History: Including cultural background.

• Review of Systems (ROS): Systematic review of each body system.

• Functional Assessment (ADLs): Ability to perform daily activities.

History of Present Illness (HPI)

HPI is a detailed account of the current health issue, using the following framework:

• Provocation/palliative factors

• Quality/quantity

• Region/radiation

• Severity scale

• Timing (onset, duration, frequency)

• Client's perception

• Associated symptoms

• Relieving factors

• Medications and treatments tried

Review of Systems (ROS)

ROS is a systematic review of each body system to identify any symptoms or issues:

• General overall health

• Skin, hair, head

• Eyes, ears, nose, sinuses

• Mouth, throat, neck

• Breast, axilla

• Respiratory system

• Cardiovascular system

• Peripheral vascular

• Gastrointestinal

• Urinary system

• Male/female genital

• Sexual health

• Musculoskeletal

• Neurologic system

• Hematologic system

• Endocrine system

Functional Assessment

Functional assessment evaluates the patient's ability to perform daily activities and maintain health:

• Self-esteem/self-concept

• Activity/exercise

• Sleep/rest

• Nutrition/elimination

• Interpersonal relationships/resources

• Spiritual resources

• Coping and stress management

• Personal habits

• Environmental/occupational hazards

• Intimate partner violence

• Health perceptions and goals

Considerations for Children

Health history for children includes:

• Prenatal status

• Course of labor and delivery

• Postnatal status

• Developmental history and milestones

• Current development (1 month – preschooler)

• Nutritional history

• Family history

• Review of systems and functional assessment

• Adolescents: HEEADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety)

Considerations for Older Adults

Health history for older adults may require more time and focus on:

• General health in the last 5 years

• Last examinations

• Current medications (watch for polypharmacy)

• Functional assessment: Ability to perform ADLs

Sample Question: Open-ended vs. Closed Questions

Open-ended questions encourage patients to elaborate and share more information. For example:

• Open-ended: "What concerns do you have today?"

• Closed: "Do you have any pain?" "How many days have you been hurting?" "Where does it hurt?"

Correct answer: D. What concerns do you have today?

Summary Table: Open vs. Closed Questions

Type	Purpose	Example
Open-ended	Encourage narrative, detailed responses	"What concerns do you have today?"
Closed	Obtain specific information, short answers	"Do you have any pain?"

Additional info: The HEEADSSS assessment for adolescents is a widely used psychosocial screening tool.