“A guide to taking a patient’s history” is an article published in Nursing Standard Journal in the December 2007 issue. This article was written by Hilary Lloyd and Stephen Craig. The authors of this article provide a guide for taking a comprehensive and accurate history from the patient. Each of the sections in the article provides best practice applications in regards to communicating with the patient. The article also gives an overview of cardinal symptoms to be explored during the assessment of the presenting complaint.
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Summary of Article
The article begins with a discussion on the importance of environmental preparation. As nurses we interact with patients in a variety of settings including in-patient hospital beds, doctors’ offices, emergency rooms and patient homes. Each of these environments presents challenges to the nurse during the interview process. Respect for the patient during the interview process “involves maintenance of privacy and dignity; the environment should be quiet and ideally, there should be no interruptions” (Lloyd & Craig, 2007, p. 42).
Good communication skills displayed by the nurse during the interview are essential to the success of the history taking process. The nurse needs to approach the patient with respect and show an interest in what the patient is saying. Questions should be open ended and avoid the use of medical terminology that the patient may not understand. Examples of non-verbal and verbal communication skills are listed. The authors stress the importance of not making the patient feel rushed when they are talking and allowing them to ‘tell their story in their own words” (Lloyd & Craig, 2007, p. 42). The ability of the patient to give consent is briefly discussed.
The article then focuses on the systematic approach to the health history process. This begins ultimately with an introduction by the nurse along with advising the purpose of the interview and obtaining consent from the patient. It is important during this introductory period to find out how the patient would like to be addressed. The article recommends that the taking of the patient’s health history follow a clear and organized process. However, although a set order is recommended they stress that “it is not necessary to adhere to these rigidly” (Lloyd & Craig, 2007, p. 43). During the interview the nurse uses open-ended questions in an effort to make sure that nothing is omitted. When the nurse needs to clarify or direct the patient closed questions can be used. By reciting back to the patient your understanding of what they have said you allow the patient the opportunity to rectify any discrepancies. Interview techniques become more developed with practice.
The patient begins the history taking process by discussing their complaint. The nurse can help assist the patient by using open ended questions regarding their problem. The article discusses the importance of the nurse asking all of the cardinal symptoms of each specific body system mentioned by the patient. For example, if the patient complains of abdominal discomfort after eating the nurse would also ask about the patients current bowel habits, stool color, nausea and swallowing difficulty. The nurse then asks the patient questions to obtain a more accurate record of the patient’s problem.
After the presenting problem has been discussed the nurse can move onto the patients past medical history. It is important to find out how the medical diagnosis, date of occurrence, sequence of the illness along with medical management. The nurse needs to ask the patient about any current mental health issues or current inability coping with stress. Another critical portion of the health history interview is the patient’s current medication regimen. The nurse obtains a list of the patient’s current medications along with the route, dosage and frequency. It is important to find out of the patient takes any over the counter medications or herbal remedies. Another important question during this part of the interview is how compliant the patient is with taking the prescribed medications. Lastly, does the patient have any medication allergies?
The next topic to be discussed during the health history is the patient’s family history of illnesses. During this topic it will be important for the nurse to find out about each family illness along with the age that it was diagnosed and if relevant age and cause of death. The patient’s social history includes the patient’s ability to cope with stress and form relationships. It is during this part of the interview that the nurse needs to inquire on current level of alcohol intake, smoking and recreational drug use. Care should be taken during the inquiry into the consumption and use of these substances. Questions should not be accusatory or judgmental. If it is deemed appropriate the nurse may need to broach the subject of the patient’s sexual history. The patient’s current and past employment needs to be touched upon during the interview. Lastly, the interview concludes with the nurse asking the patient questions about body systems not presented during the opening complaint. If necessary the nurse may find it necessary to collect missing or additional information from the patient’s family or friends (with their permission).
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Evaluation of Article
This is an in depth article full of practical information to guide the nurse in taking a complete health history from a patient. The authors provide insight on how to best prepare the environment for the actual interview along with guides on using open communication. The layout of the information is easy to read and displayed in a format that makes it easy to use as a quick reference. The article enforces the need for the nurse to follow a certain order during the process. This will allow the nurse to systematically move from one subject to the next and additionally decreases the chances of the nurse missing information.
The cardinal symptoms for each body system are displayed in a large box format to help the nurse easily see how each question correlates to that system. The only complaint is the laws regarding obtaining patient consent not being applicable for the United States.
Conclusion
In conclusion this article provides the nurse with a practical overview of taking a patient health history. The suggestions for using open communication with examples will enable the nurse to complete a more complete patient health history. Information is presented in any easy to read format that allows for quick reference to each topic. Lastly, the article will be a helpful guide for the nurse, whether novice, expert or in between.
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