“A Guide to Taking a Patient’s History”: Article Review

Introduction

The article reviewed here is a journal entitled “A guide to taking a patient’s history”, written by Hilary Lloyd and Stephen Craig. The Journal was published on 24th August 2007.

Summary of the Article

The Journal discusses the procedure of taking a patient’s history. It takes into consideration various aspects such as; environment preparation, communication skills, and relevance of the following order. According to Lloyd and Craig (2007), taking a patient’s history need to start from environment preparation, introducing oneself, asserting his or her purposes, and getting the consent of the patient. Also, taking a patient’s history needs to follow a given order. They outline the order as: The presenting complaint, previous medical history, psychological health, treatment history, family history, social history, sexual history, work-related history, general inquiry, and further information from a third party. During presenting complaints both open-ended and direct questions can be used to get as much information as possible. While open-ended questions provide information about the symptoms of the complaint, direct questions give information about the event sequence of the symptoms. Previous medical history gives important background information. It should capture useful information such as diagnosis, periods, order, and management. The psychological health of the patient can be evaluated using communication skills. This helps in determining if information the patient gives is true and can be relied upon.

Treatment history takes into consideration both the medicine the patient uses presently and those that were used earlier bought or prescribed by a doctor. Specific information such as dosage, generic name and changes experienced due to usage can be determined. Since there are illnesses that are genetic, getting a family history is very important. Information about family history can be gathered using open-ended questions. The social history of the patient involves the analysis of the wellbeing of the patient. This is important because it determines how well a patient copes with health change. Queries that need to be asked here should be related to the ability to work or engage in holiday activities and doing household duties, like cooking and shopping. Assessment of social history should also consider family history and socializing with friends. When inquiring about addiction, such as alcohol, the nurse should ask about the past and present patterns of alcohol intake. This also applies to inquiries into smoking as well as other drugs. The type and amount of cigars or drugs used should be inquired.

Sexual history is important to gather information about the sexual health of the patient. This includes history of urinary tract infection, sexually transmitted diseases, and treatments used. In women, menstruation date, consistency and character of menses should be inquired. Sexual history should also include risky sexual behaviors in both men and women. Occupational history includes information about past and present work. This is essential because it influences the social well-being of a patient. Additionally, occupational history information indicates the past or current financial stability of the patient and/or how a certain illness develops. Finally, system inquiry involves asking general questions about the patient that may not be related to the complaint. The procedure is important to make sure that no information is omitted.

The Journal also discusses important tools and strategies used in the health assessment. First, the authors stress the importance of preparing the environment for health assessment. It states that the environment should be accessible, aptly equipped, interruption-free and safe for both patient and the nurse. Respect and proper communication are important strategies in gathering information from the patient. Respect includes considering the values and beliefs of the patient. Both verbal and non-verbal communication are important strategies in communication. Good verbal communication involves the use of good language, avoiding jargon and technical terminologies, using good pitch, volume and rate of intonation. On the other hand, non-verbal communication involves the use of gestures, facial expressions, hand signs, maintaining eye contact, and nodding of the head.

Evaluation of the Article

This article is well written and comprehensive though it does not outline steps of inquiry at every stage of the assessment process. However, the article is interesting especially because it is written in simple language. The health assessment strategy is beneficial and can easily be adopted because it is clearly explained. Nonetheless, more articles need to be written to explore much information on health assessment. Both nurses and students will find this information useful.

Conclusion

The article is very useful because it gives information on how to assess the health history of the patient. Health assessment of a patient is important to know the illness, its stage of development, and the correct prescription to give to the patient. It also helps in determining the best management approaches to use. The article provides a great guide to taking the history of the patient. The steps outlined include The presenting complaint, previous medical history, psychological health, Treatment history, Family history, Social history, Sexual history, Work-related history, and general inquiry. Finally, important strategies such as communication and respect are also discussed.

Reference

Lloyd H, Craig S (2007) A guide to taking a patient’s history. Nursing Standard. 22, 13, 42-48.