A Guide to Taking a Patients History

Introduction

The process of taking history of patients is regarded as the most significant aspect of professional assessment of patients and is in most cases undertaken by nurses. Taking patients’ history enables the patients to provide a written overview of important information to the practitioner with regards to their ailments. This process of taking patients history has expanded the roles of nurses although it is undertaken alongside other information collection means such as nursing assessment and single assessment process. Critical assessment of the needs of patients has enabled health deficit examination among patients and good nurse to patient relationship. When taking patients history, nurses first undertake to prepare the environment after which effective ways of communication between the patient and the nurse are established.

Summary of the Article

History begins with environment preparation, since there are a variety of environments where patients’ needs are to be addressed. The environments may include the general wards, emergency ward, primary care units, and patient’s home environment, which are accessible, safe, well equipped, and free from interferences. The environment should also be quiet and private to facilitate maintenance of patients’ self-dignity, personal values, and beliefs where nurses act professionally to uphold respect for their patients. Nurses have a duty to ensure that confidentiality of the patients is maintained with regard to the full information offered by patients.

Effective, systematic, and professional communication with patients is important for achievement of comprehensive information about the patients’ history. Nurses should be able to establish a good rapport and use verbal and non-verbal skills of communication to encourage patients to disclose their history. During history taking, code of professional conduct insists that there should be informed consent from the patient who has the ability to act on his/her own free will, given that he/she has adequate information of the decision. Patients give consent for the history taking with the knowledge that nurses taking the patients history must adhere to local policies and health trusts.

Patient’s history taking follows general principles, which include environment preparation, introduction of oneself and purpose the gaining the patients consent. The process involves taking the patient’s personal identity details in a specific logical and systematic order. When questioning the patient, nurses should always start with open-ended questions than closed ended questions to ensure that no information is left out. After all relevant intended information has been gathered, the nurse needs to seek clarification from the patient to ensure the information is right and has no discrepancies. Guidelines such as making observation to enable the patient to reflect and focus on the discussion are important.

The steps of taking patients’ history include verification of information, enabling patients’ recalling and understanding, incorporating the patients’ and professional perspectives and lastly, involving patients in decision-making. The patient then presents complaints and gives a brief overview of past medical history concerning diagnosis, dates, sequence, and management of the past complaints. Nurses need to include assessment of mental health problems, after which the current and past medication taken by the patient are taken with the generic name, dosage and route of administration being considered.

Among the information to be recorded is concordance, allergies and sensitivities of the patient with the medication and reason for non-concordance, if any. Family history with regards to specific disorders should also be recorded alongside the patient’s social history, such as past and present alcohol consumption patterns, which in one way or another affects ability of patients to cope with their health difficulties. The information concerning social history not only involves alcohol consumption patterns, but also occupational history, smoking and sexual behaviors. The last part of patient’s history taking is the enquiry of systemic functioning of other body parts to ascertain that no vital information is left out.

Evaluation

This is an informative article that presents an overview of how to take a patients’ history and what specific information that should be included. After a careful analysis of the article, a better understanding of the preparation of the environment and best ways of communicating to the patients is developed. The article provides a step-by-step procedure of how nurses taking patient’s information should take a patient’s history. The author of the article draws the attention of the nurses on the importance of maintaining confidentiality and gathering information under the patient’s informed consent. The article enables a healthy relationship between the patient and the nurses with the use of both verbal and non-verbal communication skills. The author does not only focus on patient’s history taking, but also the general assessment of a patient’s identity details, medical history, medication and social history with regards to the patient’s health.

The Knowledge gained from this article is clear and can be practically applied by nurses and medical practitioners taking patient’s history. However, the details covered in the section that contains social history information has more concentration than needed but still remains relevant to history taking.

Conclusion

The history taking guide article provides important information with regards to how nurses should take the patients’ history and relate to them for best disclosure of information. The article focuses on the use of communication skills to encourage patients to disclose all relevant information required by the health practitioners. More to this, the article gives specific information about the question that nurses should use to get adequate information from their patients.

References

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