Taking a patients history

Introduction.

" A guide to taking a patient's history" is a post released in Nursing Requirement in the December, 2007 concern, composed by Hilary Lloyd and Stephen Craig. In this short article, Lloyd and Craig lay out the procedure of taking a total health history from a patient. The reasoning for gathering a detailed history is likewise described. There are also tables and boxes of examples that can be utilized as examples, while obtaining health information. This article likewise offers an overview in which to take a full and detailed history from a client and the order and structure to follow.

Summary of Article.

There are a particular set of steps that are taken when taking a patient's history. The firstly action is identified, preparing the environment. It includes finding a location to complete evaluation that is totally free from sound and interruptions, allowing ample time to complete task and maintaining patient regard. Interaction follows, with focus on an excellent introduction and developing a good relationship with the patient in order to collect info in an expert and sensitive way.

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Great interaction tools are essential, utilizing the proper verbal and non-verbal abilities reveal the client that you have an interest in the subject at hand. Yet, before any individual concerns are asked, approval must be obtained. After this is acquired, the procedure starts. Since the preparing of the environment and intros have been done, the next action would be to get the general group details from the client. It is mentioned in numerous books that they patient history must be performed in a set order, but it is not necessary to follow it so strictly.

It is crucial to know when to utilize open and closed questions.

Open questions ensure that all information is sought out and nothing is left out. Closed questions are used to clarify and focus on getting specific answers. Always clarify responses to summarize your understanding of the information provided to you. Encouraging participation and agreement allows the patient to feel comfortable and more willing to comply with assessment. According to Kurtz et al (2003), there are five suggested stages to summarize taking a patient’s history: Explanation and planning, Aiding accurate recall and understanding, Achieving a shared understanding; Planning through shared decision making, and Closing the consultation (as cited in Lloyd & Craig, 2007). These steps involve giving the patients accurate information and agreeing on the history provided. Reflection is used to simplify information. Interactions are encouraged using the patient’s perspective. Patient involvement is essential when making decisions.

Lastly, explaining, verifying and offering a care plan that is acceptable to the patient’s needs. History taking should begin with the presenting problem and open ended questions are asked at this time to obtain pertinent information. Direct questioning should be used when needing specific answers to questions. Past medical and medication history follows in the assessment. According to Lloyd and Craig (2007), most textbooks provide a list of cardinal symptoms- that are most important to that body system; when a patient reports symptoms from a specific system, all cardinal symptoms in the system should be explored.

Family and social history should be obtained next, which also includes alcohol, smoking and drug use, as well as levels of daily function, marital status and employment history. When obtaining sexual history, acknowledge that the subject is sensitive, but only relevant questions will be asked. After all other questions are answered, a systemic evaluation is done. Questions are asked in relation to the other body systems that were not discussed in the presenting problem, to ensure no other information has been omitted. All information gathered is essential and will assist in guiding the treatment of the patient.

Evaluation of Article

This is a very interesting and informative article, which outlined in great detail, all the information needed to perform a complete and comprehensive patient history. The more detailed and comprehensive an assessment is, the better understanding we have of our patient’s and the plan of care that we will follow to ensure they are taken care of. After reading this article, I have a deeper insight into understanding the need for a structure when performing a health history. The detailed descriptions that were provided will enable one to use the specific examples when questioning a patient, ones on which I plan on implementing in my practice. I found this article very well written and explained thoroughly, as it is a great representation of a well-completed history. In my daily practice as a nurse, I follow a specific format for completing a patient history and assessment; it very closely resembles this model.

I find that when initiating a patient’s history, I begin with asking all pertinent questions in relation to presenting problems, and all historical information. I then follow with a hands-on assessment, I listen to breath sounds and heart rhythms while asking questions related to those particular body system. Listen for intestinal sounds when asking questions about dietary habits. I engage the patient in their assessment so they feel a sense of trust and willingness to cooperate in their care.

I believe that more articles could be written about performing a patient’s history, yet all articles written would be one’s opinion on how to proceed with the task. All nurses complete their history and assessments differently, and it would be beneficial to have additional articles written with different views and plans on how to complete the same assessments. All nurses and health professionals would benefit greatly from this article. It can be changed to adapt to all sorts of questions, such as from nurse-aides, respiratory technicians, physical therapists and even doctors, just to name a few.

Conclusion

This article provides a useful guide to history taking using a systemized approach. The process of obtaining a patient’s history is essential in delivering top notch healthcare. When utilizing the proper steps, which include preparing the environment, using excellent communication skills and following the specific order of questioning, a clear picture of the patient and how to go about treating them, is depicted. The benefits for proper assessments on patients are, ensuring the best possible care is given, making sure all information provided is utilized when being diagnosed by the doctor, and gathering all information to rule out other possible problems.
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References
Lloyd, H., & Craig. S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13),
42-48.