In the December 2007 issue of Nursing Standards, Hilary Lloyd and Stephen Craig explain the process and importance of taking a full and comprehensive patient health history in the article, “A guide to taking a patient’s history”. General principles, tools and strategies are outlined in this article to assist the nurse when performing a health history assessment for a patient in any setting. Summary of the Article According to Lloyd and Craig, taking a patient history is the most important aspect of patient assessment because information from the history is essential in guiding the treatment and management of the patient (p. 8).
In this article, these two authors provide the reader with an easy to follow guide to professionally collect accurate patient information from the generalized public that is organized and prioritized through a systemic approach. The first step of this systemic process is preparing a professional, safe and private environment that is free from distractions so the patient feels comfortable disclosing confidential information to the nurse. “The nurse should be able to gather information in a systemic, sensitive and professional manner. Good communication skills are essential. ” (Lloyd & Craig, 2007).
Introducing yourself, using active listening, avoiding jargon, maintaining eye contact and holding an interested posture are examples of good communication skills. “It is important to use appropriate questioning techniques to ensure nothing is missed when taking a patient history. ” (Lloyd & Craig, 2007). Begin the assessment process by using open questioning to discuss the presenting complaint to gather information. Then clarify this information with closed questions by focusing on cardinal symptoms. According to Lloyd and Craig, it is important to concentrate on symptoms and not on diagnosis to ensure that no information s missed (p. 44). After the presenting complaint is addressed the assessment continues to past medical history to provide essential background information, mental health history, medication history, family history, social history, sexual history, and occupational history.
“The final part of history taking involves performing a systemic enquiry by asking questions about the other body systems not discussed in the presenting complaint. The purpose of this is to check that no information has been omitted. ” (Lloyd & Craig, 2007). Evaluation of the Article A guide to taking a patient’s history” is easy to follow because this article is well organized, the process is explained clearly and rationales are provided to educate the reader. Having the answer to the question why makes it easier to adopt this assessment approach in one’s practice. Allowing sufficient time to complete the history, using the patient’s own words and performing systemic enquiries that focus on cardinal symptoms are identified points of interest and strategies that will be adopted to enhance the accuracy, safety and professionalism of my practice.
Elderly patients, children and adults with lower educational levels can benefit from this assessment strategy because they may be unfamiliar with medical jargon such as diagnoses, symptoms and medication names. Using patient friendly terms assists the nurse in collecting more information from the patient because these common words are easier for the patient to understand and relate to their body systems. More time may be needed when performing a health history assessment with an elderly patient due to age related sensory deficits.
More research should be done regarding this type of assessment approach because many times crucial information is omitted due to lack of time, distracting environment, and the nurse’s lack of assessment skills. This assessment procedure could be improved by including an assessment of the patient’s learning preferences, educational level, language spoken and ability to read. A part of delivering patient centered care is educating the patient so they understand their health plan and be knowledgeable about their disease process so they are able to manage their own health at home.
Conclusion “Information from the history is essential in guiding the treatment and management of a patient. ” (Lloyd & Craig, 2007). This is why it is important to gather accurate information by using an organized systemic approach. By preparing the environment, using good communication skills and focusing on order, cardinal symptoms and clarifying answers the nurse is able to deliver safe, professional, patient centered care.