Journal Review of a Guide to Taking a Patient's History
Introduction “A guide to taking a patient’s history,” is an article published in Nursing Standard in December 2007, written by Hillary Lloyd and Stephen Craig - Journal Review of a Guide to Taking a Patient's History introduction. The article provides an overview of the process involved in taking a patient history including factors such as; the environment, importance of following a logical order when taking the history, and communication skills. Summary of Article This article focused on the importance of taking a comprehensive health history and pointed out that this task is increasingly being undertaken by nurses.
The article proposed that taking a logical, systematic approach when taking a patient’s health history allows for the most comprehensive collection of information. The article identified the Calgary Cambridge framework as a model for use during the interview process and stated that it is helpful for both new and seasoned nurses. It provides five suggested stages to implement during the interview process which include; explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation (Lloyd & Craig, 2007, p. 4) One of the first things that should be considered when taking a history is the environment, as patients may be encountered in various environments. The article pointed out that safety must be considered, as well as respect for patient privacy. When beginning a patient history the nurse should provide an introduction to the patient and an explanation of the purpose of the interview. The patient must then give consent for the interview to proceed and must demonstrate they have a clear understanding of what they are consenting to.
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Once consent is obtained the nurse begins gathering information, asking open ended questions such as, “What are you experiencing? ” which allows the patient to explain in their own words what is going on at the present time. After the patient has had the opportunity to present their complaint the nurse can then explore further with closed questions that will help to obtain additional information including; the onset of problem, the duration, the site and possible radiation, aggravating and relieving factors, associated symptoms, fluctuating vs. onstant and the frequency which it occurs ( Lloyd & Craig, 2007, p. 44). Further questions can be asked about specific body system/ systems utilizing a list of cardinal questions specific to that system. The article cautioned not to concentrate solely on a diagnosis, rather to focus on the symptoms being presented to avoid overlooking information. The patient history should be taken in a logical sequence, beginning with the present complaint and then proceeding to the patients past medical history.
Past medical history provides important background information and should include diagnosis, dates, sequence and management of any health problems. Mental health is then addressed which is important, in that, it helps to identify coping strategies the patient may utilize. Additionally, it can help identify any current or past psychiatric issues. A medication history is then taken and allergies are identified.
The article highlighted the need to ask specifically about over the counter medications as well as herbal remedies, as some patients may only think to mention medications that have been prescribed by a healthcare provider. Family history is then addressed which is important as it can provide a history of disease in family members, this helps to identify increased risk for patients in diseases that tend to be familial. A social history is then taken and provides information about the patient’s resources, support systems, and the ability to deal with health issues.
Social history includes assessment of patient’s alcohol usage and the article recommends using the Cage system which utilizes four questions and can help to identify those who may have issues with alcohol use. Smoking history is also taken as part of the social history and usage calculated in pack years, “The pack year number is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked,” ( Lloyd & Craig, 2007, p. 47). Sexual history is then taken and should be broached in a sensitive manner.
Male sexual history can be included as part of the genitourinary system and should include; past urinary tract infections, as well as, any sexually transmitted infections (STI’s) and treatments. Female assessment should include date of last menstrual period, regularity of periods, characteristics of period, as well as number of pregnancies, terminations, and past STI’s. With both genders inquiry should be made about possible high risk behaviors and libido which can be reflective of both psychological and endocrine function.
Occupational history is taken next and provides information about the patient’s previous and current employment. This can be important as it can impact the patient’s social wellbeing. It also provides information about how illness will affect the patient’s ability to work, as well as their financial circumstance. The final part of the history involves systemic inquiry and covers any systems areas that have not been previously covered. Collateral history can also be obtained from patient’s friends or relatives and is a good source of additional information. Evaluation
This writer thought this article was well written and covered the important aspects that should be considered when taking a patient’s history. One improvement that could have been made would have been to include a section on taking a patient history from a patient who is unable to provide it or has limited ability to do so, such as pediatric patients or those who do not have the cognitive ability to provide accurate information. This writer found the article interesting and appreciated the logical sequence that was suggested as a template for taking a patient history.
The article did a good job of explaining why this assessment strategy is a good one to utilize and this writer felt that the rationales provided for each step in the patient history sequence were comprehensive and logical. This writer feels there is always room for further research in any area, this one included, and that improvements can be made by analyzing current practices and identifying areas that work and areas that are lacking. A group that would benefit from the information provided in this article would likely be the elderly population.
As people age and begin to develop multiple health issues, with multiple medications to treat those issues, it becomes even more important to make sure that an accurate patient history is available. Additionally, the elderly can often be a vulnerable population due to lack of resources and declining ability to meet self-care needs. Through the collection of a thorough patient history social and psychological issues can be identified, as well as medical issues. This writer feels that this system could be adopted into personal practice as it follows a logical sequence and would assist this writer in gathering a comprehensive patient history.
Conclusion This article covered the importance of obtaining a thorough patient history. It addressed the need to gather the information in a logical sequence, as well as, the need for clear and therapeutic communication. As the article pointed out, “Taking a patient history is arguably the most important aspect of patient assessment…” (Lloyd & Craig, 2007, p. 42), with this in mind nurses can utilize the strategies outlined in the article and gather comprehensive patient histories on their patients. References Lloyd, H. , & Craig. S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13), 42-48.