PATIENT HISTORY

A Guide to Taking a Patient History



A Guide to Taking a Patient History

Introduction

In the article titled 'A guide to taking a patient's history,' H. Lloyd and S. Craig propose a process to obtain patient history. The key phases of the process include preparation of a suitable environment, smooth patient-carer communication, and adherence to NMCs guidelines of record keeping. The authors also explain why it is important for health care providers to ensure that they obtain a comprehensive patient history.

 

Preparing the Environment

According to the authors, nurses encounter patients in diverse environments like general wards, accident and emergency, primary care centers, and patient's homes (Lloyd & Craig, 2007). Therefore, a nurse must be familiar with how and where to look for equipment, and how to deal with distractions, if any. An environment where patient-provider privacy is compromised, or where distractions would possibly lead to a faulty record keeping, should be avoided.

 

Communication

A sensitive, systematic and profession way of information gathering is essential. In other words, good communication is the key to effectively recording patient history. A nurse must adapt active listening skills and avoid rushing and interruption. Practitioners are advised not to use jargon, and use the patient's own words for clarifying information. Both verbal and non verbal communication plays a role in information generation. Good nonverbal cues like eye contact and pleasant facial gestures are as important as verbal cues like appropriate language, volume and pitch (Thomas & Monaghan, 2007).

 

Consent

All health care interventions, including obtaining patient history, must precede an informed patient consent (Lloyd & Craig, 2007). Though the Codes of Professional Conduct (NMC 2004) and Good Practice in Consent Implementation Guide (DH 2001) hints that some patient might not be able to act under free will while giving consent, an understanding of the underlying significance of informed consent, as provided in regulations like Mental Capacity Act 2005 and Adults with Incapacity Act 2000 is advisable.

The History Taking Process

The general principles nurses must follow when gathering information include the nurse-patient introduction, an ordered structure of questions regarding present complain, past medical family, social, sexual and occupational history, medication, and summary.

 Lloyd identifies some of the poor patient interview techniques that may lead to false or unfair information (Lloyd & Craig, 2007). These include giving false reassurance, using stereotype responses, jumping to a conclusion and using defensive language in response. When a patient reports symptoms from specific body system, the author argues, then all of the associated symptoms must be explored. For instance, if the patient complained about palpitations, questions relating to chest pain and breathlessness must follow. The key is arriving at the most evident symptom when a patient reports multiple problems.

Evaluation of the Article

The medical history is the basis for all treatment given by the primary care provider, on-call provider, any other provider, and any specialist consulted to treat a patient. During the history-taking process, information is revealed to help guide treatment for the patient. The medical history makes it easier to recall ...