‘A guide to taking a patient’s history’ is an article published in the Nursing Standard Journal, volume 22, issue 13, dated December 5, 2007, written by Hillary Lloyd and Stephen Craig. In this article, Lloyd and Craig describe the most effective and professional way to take a history from a patient in a variety of settings and the strategic reasons why doing so will achieve the best results. Summary of Article
Hillary Lloyd works for City Hospitals Sunderland NHS Foundation Trust, Sunderland and Stephen Craig works for Northumbria University, Newcastle upon Tyne, and both are senior nursing lecturers in the area of history taking and nursing assessment (Lloyd & Craig, 2007 p. 42). In this article, Lloyd and Craig explain how using a systematic approach to taking a patients history can be done precisely and professionally and will gain the most accurate record from the patient.
Preparing the environment, communication styles, obtaining consent and history-taking process are the major components in the sequence of questions the patient is asked throughout the interview (Lloyd & Craig, 2007 p. 42-44). Taking a patient’s history will happen in all types of situations and in all kinds of environments. For these reasons, there is some “set-up” that needs to take place before the interview can begin. The nurse needs to make sure that the patient is as comfortable as possible, both physically and mentally.
The nurse should also attempt to make the room free of distractions to ensure that the patient has adequate time to answer questions and no information is missed. The nurse needs to try, to the best of her ability, to give the patient respect and dignity no matter what environment they are in. This will enable the patient to trust the nurse which will ensure that even the most delicate of topics are talked about. One of the most important steps before the interview can begin is getting consent from the patient. Laws governing HIPPA and patient confidentiality are major legal issues in hospitals today. Lloyd & Craig, 2007 p. 42). The history-taking process starts with good effective communication. By using proper introductions, maintaining order and structure, using open-ended questioning and using clarification, a nurse can obtain much needed information in a short amount of time. It is identified in both nursing and medical texts that a systemic approach to the interview will warrant the best results. Open-ended questioning is essential to a successful interview and enables the patient to tell their “story”.
Closed questioning, for instance, “Is the blood bright red or dark red” provides key elements to the patient’s account. Clarification involves repeating back to the patient their story, in their own words, to check that what was heard is accurate and to correct any information that was misheard or omitted (Lloyd & Craig 2007 p. 43). The actual history-taking sequence is a step-by-step checklist that a nurse can follow from beginning to end and it covers all important or “cardinal” symptoms associated with each body system.
In following these steps, a nurse can be sure that any potential problems are red-flagged to show symptoms which may need to be investigated further. These steps include the presenting complaint, any past medical history, mental health issues, medication history, family history, social history, sexual history, occupational history, systemic enquiry, further information from a third party and summary” (Lloyd & Craig 2007 p. 43). Presenting complaint is usually always the very first question that anyone asks a patient and it needs to be an open-ended question.
The patient needs to be able to give there “story”, in their own words and then, when the patient is finished, the nurse can go back to the complaint and ask about important or “cardinal” symptoms that go along with that body system (Lloyd & Craig 2007 p. 44). Past medical history is basically just that, any time a patient has gone to see a doctor and been prescribed medication for any serious illness or had any operations. There are 4 important questions to ask when assessing past medical history: Diagnosis, Dates, Sequence of events, and Management (Lloyd & Craig 2007 p. 45).
Mental illness is prevalent in today’s world and nurses have a 1 in 4 chance of taking care of a patient with a history of mental illness, either acute or chronic. It is important to ascertain if the patient is suffering from any mental conditions because it will tell a lot about how the person may or may not be able to take care of themselves (Lloyd & Craig 2007 p. 45). Medication history is one of the most important items in a patient’s history since it tells the nurse exactly what the patients suffers from. If the patient isn’t a good historian, having a list of medications can tell all about a person and what their history involves.
But, it is important for the nurse to not assume that a patient suffers from one disease if the medication he/she is taking can treat a variety of diseases. By using the patient’s medical history and medication history, important information can be provided (Lloyd & Craig 2007 p. 45-46). Family history is vital to the patient’s interview since some diseases are genetic and put patients at an increased risk because their mother/father, grandmother/grandfather, and/or brother/sister suffered from a specific disease.
Heart disease, diabetes, cancer and multiple sclerosis are all genetic diseases (Lloyd & Craig 2007 p. 46). Smoking, alcohol consumption, illicit/recreational drug use, activities of daily living, occupation and family situation all fall into the category of Social history. These questions are important to the interview, as it shows coping mechanisms, support persons at home and any life changing events which could have attributed to the state of health that the patient is in currently (Lloyd & Craig 2007 p. 46-47).
Sexual history needs to be handled with delicate but professional manner and if the questions are asked in an objective but sensitive manner, the nurse should have no problem gaining trust and accurate information from the patient (Lloyd & Craig 2007 p. 47). Occupational/Work history and type of employment, along with financial information plays an important role in assessing for ability to pay, unemployment and financial strains. Not to mention, a patient’s need to be taken care of once home by another family member or agency and their ability to return to work (Lloyd & Craig 2007 p. 47).
The final step in the interview process is called a Systemic enquiry. What this entails is basically asking any questions about any body system and its “cardinal” symptoms that were not included in previous questioning. Another part of this final step is to gather any information from friends or relatives that are vital in the care of the patient. They may provide information about the patient that the patient has not disclosed or was unable to disclose in the questioning. And finally, a summary of the entire interview to make sure information is accurate and nothing important was missed (Lloyd & Craig 2007 p. 8). Evaluation of the Article This article was both interesting and full of excellent information regarding proper and complete history taking assessments. Although this history-taking process is quite in-depth for the average bedside nurse, it would be rather useful for advanced practice nurses like nurse practitioners and CRNA’s. I think this article was done well in regards to, ease of understanding and fast reading. It didn’t skip around, it was very step by step, and it gave enough of an explanation but not too much, it included specific examples so I knew exactly what the authors were referring to.
I believe that the article could have included some American data to make it a little more user friendly for US nurses. The thing I mostly liked about it was the fact that any nurse could make a copy of the History-taking steps, they could cut it out and laminate it and stick it in their pocket. What an extremely useful tool to have. One of the best parts of this article was that it takes the guessing game out of trying to remember all the important bad symptoms associated with each body system. They are printed in a nice graph and show which complaints need additional information to rule out high risk illnesses.
The article is great, in my opinion, because it stands the test of time and doesn’t ever fall in the “needs to be updated” category. The questions that are asked of the patient are always the same ones in the same sequence, and get to the bottom of the problem. The body is a complex system that runs like a well oiled machine, but sometimes problems arise and it’s up to health professionals, like nurses, to be detectives, ask the right questions to narrow down the millions of possibilities that could be causing the symptoms. Conclusion This article provides step-by-step instructions for interviewing a patient from start to finish.
Not only does it make a history-taking interview extremely clear cut, but it also gives the reasons why the questions are important and what you are looking for when you ask those questions. This article should be in the front of every Nursing 101 book and the students should have a copy of it in there clinical folders. Most of the sequence is learned, thoroughly, after asking the questions a million times over many years. We should put this step-by-step into use while in nursing school so that it becomes second nature when nursing students graduate. What excellent nurses we would have right from the start.
Lloyd, H., & Craig. S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13), 42-48.