Nurses Can Use to Obtain and Capture

¶ … nurses can use to obtain and capture a patient's medical history. The importance of these processes is to ensure that there will not be inadequate patient assessments, as these may result in adverse outcomes during the patient care. Preparation of the environment, good communication skills and ordering of the questions are very important in the process of acquiring patient history. There is no specific population stated in the article, but it leans towards adult patient history.

The outlines steps are mostly generic and can be applied for anyone, though that would require alteration, and addition of special skills when handling pediatric patients. The article also explains the rationale that can be used to ensure a nurse takes a comprehensive patient history. Summary of the article In all patient assessments, the most important thing is taking a patient's history. This is part of the whole process and has its imperative to use it together with other information gathering techniques.

The other techniques include, nursing assessment and single assessment process. The accuracy of this information gives the health care providers and practitioners with the best possible information regarding the patient. For proper gathering of the patient's history, the environment should be prepared well in advance. There is no telling where a nurse will encounter a patient Lloyd & Stephen, 2007. Therefore, it is of utmost importance that these environment is well prepared.

The environment should be conducive to allow for easy access by the patient, safe, well equipped, and there should be no distractions for the nurse and patient. To ensure the patient is comfortable to discuss any sensitive information with the nurse, the area should not have any distractions, and the nurse should pay attention to the patient. The area should also be private to ensure the patient is comfortable to discuss their problem without any reservations.

Before the process of history taking begins, the patient has to give consent to giving out their history. Cultural considerations of the patient should also be taken into consideration. The nurse should endeavor to create a meaningful client-nurse relationship. The history taking should be performed professionally, and the nurse is non-judgmental Buck, 2008. The patient's health beliefs and practices should be assessed, because a person's heritage gives them their health and illness perceptions. The process of history taking should begin with introductions. The introductions serve the purpose of relationship establishment.

The nurse should introduce him/herself to the patient stating their name, and finding out how they can address the patient. The next step is finding out the patient's pressing problem, followed by taking their medical history, and finding out if they have any mental health problems. The medication history is very important, next the family history, followed by social history, and finally the sexual history of the patient. The nurse has to be very sensitive to the patient when discussing with them their sexual history.

This would ensure the patient does not get uncomfortable. The patient's medical history assists the nurse establish if the patient is currently taking any medications that might conflict with medication issued during their visit. Gathering a patient's family medical history gives the nurse a window to establish if they have any genetic illnesses. The social history of the patient provides information to the nurse regarding the patient's ability to perform normal daily routines. The nurse should be an active listener, allowing the patient to tell their story.

This will ensure the nurse gives the patient his/her undivided attention, and the patient will not feel rushed. Rushing a patient could adversely affect the history taking process. Evaluation of the article The article's main purpose is to provide a guide to nurses on how they can effectively capture a patient's history. The process of capturing this information is of utmost importance as it forms the basis for all the patients' treatment and subsequent visits of the patient to the health facility.

The article gives systematic ways in which a nurse can go about when capturing the patient's information. Preparations that need to be made by the nurse of the environment to be used for taking this information and the sequence to use are provided in the article. The authors of the article have proved it is imperative that the nurses have a distraction free area for taking and capturing the patient's information.

If the environment has many distractions the patient will be uncomfortable, and the nurse might end up capturing wrong information regarding the patient. This would lead to disastrous effects as the nurse could have missed a patient's allergy or maybe worse. The nurse should always give the patient his/her undivided attention McGough, 2006. This would also make the patient more comfortable when presenting their problem to the nurse.

If the environment is not well prepared, and there is no privacy, the patient will be uncomfortable and not audible enough as they would be trying not to let their history be known to everyone. The article quotes from various sources, and that makes it a secondary source. The authors have combined their experiences and readings to provide a guideline that can be used by nurses. The article shows that a patient's history can be very important in the course of their treatment Kaufman, 2008.

By quoting and referencing from other sources, the author show that their article not only echo's what others have recommended but also provides more in depth analysis to their statements. The authors of the article went a step further and provided a sequence of how the patient's history should be captured. The article is intended for nurses who are responsible for the capturing of a patient's history.