Patient Histories Can Often Provide a Great

¶ … Patient histories can often provide a great deal of information about their condition and what the underlying causes may be. As such, taking an accurate patient history can be one of the most important aspects of a patient's visit to a medical facility. There are a number of factors that are important with respect to taking a patient's history, and they include one's ability to gain accurate information, one's ability to have a rapport with the patient that encourages trust, honesty and openness, and being very thorough, so as to not miss important information, such as current medications or past medical events. The following is a review of an article presented in Nursing Standard concerning the details of how to take a patient's history.

Summary

The article is very thorough in its instructions on how to take a proper patient history. The article begins by emphasizing the importance of taking patient histories as well as the increasing role of nurses in performing this task. The article then goes through each of specific steps of taking a patient's history.

Preparing the Environment: The author notes that the first task is to establish/find a suitable environment in which to take the patient's history. It is important that the patient's privacy and beliefs be taken into consideration and that the location be free from distraction where both the patient and the person taking the history can be safe. One of the most important aspects is that the environment allows for confidentiality, and thus before taking the history it is important to insure that this element is met. Finally, it is also important that there be enough time to take the history without any distractions or interruptions.

Communication: Communication skills are essential for taking patient histories as they are most often a product of verbal conversations between medical professionals (e.g. nurses) and patients (and/or their caregivers). The first step here is to let the patient know who you are and what your role is by introducing yourself and explaining what you are about to do with respect to taking the patient's medical history. This is where it is important to develop a strong rapport with the patient so that they feel safe and comfortable sharing their personal information. It is also important to communicate using language that the person understands, which can mean refraining from overly specific medical terminology.

Consent: Because health care information is protected by a number of pieces of legislation, it is imperative that consent be provided before any medical or personal information is collected.

The History Taking Process: The article provides some general principles to follow when taking a patient's history. In addition to the issues of providing an introduction, as described above, it is important that there also be order and structure to the exchange, as this helps to ensure that nothing is missed. There are also two very important types of questions that one must know how to use effectively when taking a patient's history. Open ended questions allow the patient to describe events in detail, while closed questions get the patient to provide very specific answers to specific questions. It is also important to clarify anything that the patient says that is not immediately clear.

The Calgary Cambridge Framework: The Calgary Cambridge Observation Guide (CCOG) provides a structured model for medical consultation and includes elements of explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation.

Taking the Medical History

The bulk of the article describes the precise details of taking a medical history and what should be included. It includes finding out specific information about the presenting complaint, including things such as time of onset, how it occurred, how long it has been going on, the place of concern, anything that makes it better or worse, related symptoms, and whether or not the condition fluctuates or remains stable. Next it is important to address the patient's past medical history, such as previous diagnoses, the dates of past events, sequences of events, and how they have managed their past medical events. Although patients are often presenting with physical ailments, it is equally important to address potential mental health concerns. Finding out what medications the patient is taking is perhaps one of the most important aspects, as it will influence what new medications can be prescribed or whether any current medications could be causing part of the problem. Similar to medical history, family history of medical conditions is also important to inquire about. Other aspects of a patient's history should also investigate their social history including aspects of their ability to cope with their health conditions. Taking information such as this helps to provide a holistic view of the patient. A patient's sexual history is also very important and although it is very personal, it must not be avoided. It is important to ask about sexual functioning and any sexual changes that may be relevant to their experiences. Occupational history information is also relevant, as working conditions or past working conditions may serve as contributing factors to the current situation or to the patient's ability to cope with the condition in the future. Finally, the history should end with a systemic enquiry designed to ensure that no relevant information was missed. This involves asking questions about cardiovascular, respiratory, gastrointestinal, genitourinary, locomotor and dermatological aspects of the patient's current condition.