Risk assessment to use in this scenario include the CRAFFT questionnaire, the HITS screening tool, and the 5 P’s of the sexual history (Ball et al., 2015). Evaluating the adolescent’s social history through a substance abuse screening tool such as CRAFFT is pertinent to determine their potential involvement with alcohol and other drugs that would have a detrimental effect on the teen, pregnancy and baby (Ball et al., 2015). The HITS tool is valid to assess the adolescent for intimate partner abuse and in home abuse, included is both verbal and physical violence (Ball et al., 2015). Before utilizing the 5 P’s of sexual history, I would inform the patient that these questions are important and are routinely asked in order to keep the patient healthy. The 5 P’s of sexuality include information regarding partners, practices, protection from STI’s, past history of STIs and prior pregnancy prevention practices (Ball et al., 2015). Five questions that this author would ask include: 1. Please tell me your name, date of birth and grade in school? 2. Please share with me what brings you in today? 3. Will you tell me about your medical history and your familial history? 4. Please tell me about your home life. Who lives in the home? Are your parents aware of this pregnancy, and if so, how do they feel about it? If not, how do you think they will react if they find out? 5. Have you thought about what you want to do about your pregnancy? In ambulatory care it is important that the practitioner have a clear understanding of the goals and expectations that the patient has for the encounter (Dains, Baumann & Scheibel, 2016). These goals can be established during the initial stages of the interview and set the stage for a positive meeting. Using effective communication in patient questioning to derive high quality pertinent information from the interview while seeking scientific evidence aligned with clinical reasoning will deliver expert care in the practitioner’s practice (Dains, Baumann & Scheibel, 2016). Thank you for your recommendation. In an attempt to use open-ended questions, I may have not been direct enough to draw out an adequate health history. I will make another attempt:
1. Please tell me your Name, DOB, Grade in school, how do you like school, grades, friends, sports? 2. Do you have any medical history such as asthma, chronic allergies or anything you can think of? Any surgical history such as appendectomy, or your tonsils removed, or anything else? Have you ever been diagnosed with any psychiatric concerns such as depression or anything else? Do you have any allergies to medications or food? Do you take any prescribed medications currently, or in the past? Do you take any over the counter medications such as vitamins, fish oil, or anything else? Are you up to date on your childhood immunizations? How was your state of health before becoming pregnant?
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- Summer '15