Taking the history of a patient is a crucial aspect of patient assessment and treatment. A good history can mean the difference between a successful patient outcome and unsatisfactory outcomes. However, taking a complete and useful history is a skill that is developed by means of training and practice; it is not some talent that is innate (Bickley & Szilagyi, 2007; McKenna et al., 2011). According to Craig (2007) nurses are increasingly being asked to take patient histories. Given these growing responsibilities nurses need training and guidelines to taking an adequate patient history. The following is a summary and critique of Craig, L. H, (2007), A "Guide to Taking a Patient's History" in Nursing Standard, volume 22, issue 13, pages 42-48.
Craig (2007) takes a comprehensive approach to explaining the interview and history taking process. This approach is applicable for most any patient population; however, Craig does not address certain cultural issues that could be important in gleaning an accurate and complete history, especially when discussing sexual issues, psychiatric issues, and other aspects of one's background that might spark some cultural tensions. Alarcon (2009) offers some insights in how to handle these issues and one's reactions to them. That notwithstanding, Craig offers some very useful information in regard to taking a complete patient history.
Craig (2007) begins with discussing issues that many other articles on this topic overlook or perhaps take for granted in regards to their importance on completing an accurate patient history. For instance, Craig is important to point out that the environment in which the history is taken should be safe and private to allow the patient to be at ease when giving their history. Craig emphasizes the importance of early rapport building by being genuinely concerned, introducing oneself, and explaining the reasoning behind all the upcoming questions before getting started with the actual assessment. Moreover, Craig stresses that the nurse-assessor be a good listener, allow patients or family members to relay information at their own pace, and not to be judgmental regarding the information that is given to them. Just doing these simple things will often result in patients or their relatives revealing information that they would not otherwise reveal without specific prompting (McKenna et al., 2011).
Even though Craig does outline a specific order for which to take the patient's history, he does not believe that it is necessary to adhere to a specific order. In a sense this may be true; however, adhering to a rigid order may also safeguard against forgetting to include important information or losing once place in the interview process if there is an interruption (McKenna et al., 2011). Craig also recommends starting with open-ended questions, and following these with closed questions and clarification queries, which is a sound strategy.
Actually, the most important issue should be the first question which is asked which is of course inquiring about the presenting complaint (Alarcon, 2009). Craig lists a very helpful series of questions that can be crucial in filtering out useful information regarding the presenting problem which I would suggest could be easily converted into a mini-checklist or structured format for one to follow using the open-ended, closed, and clarification sequence described earlier. Following a complete inquiry into the presenting complaint one should then proceed to the prior medical history again following the open-closed-clarification method. Often, patients will fill out forms listing previous medical conditions and this can be a useful guide and time saving device, something that Craig does not mention. In order to avoid redundancy and to save time nurses need to be able to read these forms quickly, learn what information to ask for based on the responses in these surveys and add important information as needed. Craig provides a useful list of symptoms that could be used as a symptom check-off list (Box 4, p 45) should one be employed in a clinic that does not have structured lists of symptoms and past medical issues to give to patients. There are a number of texts and papers that also provide comprehensive lists to use in ascertaining current symptoms and medical history and nurses should advocate for the use of such lists in their work environment in order to make the assessment process more efficient (McKenna et al., 2011).
Craig also stresses getting a good medication history, mental health history, family medical history, social and sexual history, and substance abuse profile and provides sufficient guidelines to obtaining relevant information for these domains. The medication history is crucial as is the family medical history and mental health, but some may not view the patient's full social history, occupational history, and sexual history as crucial in many contests. Depending on the context and presenting complaint this may be true; however, there are certain aspects of a patient's social history (e.g., is the patient married) that are crucial. In terms of the patient's occupational and even educational background it may initially be sufficient to ask a few relative questions such as is the patient employed and what kind of work do they engage in as well as their highest completed level of education. Such information may provide useful helpful hints on how to communicate with the patient, the patient's level of understanding, and the patient's support group. It may not be necessary to initially complete a full social-psychological profile of a patient. In terms of asking a patient their sexual history, this is a sticky question in many contexts, and it might be more useful ask for relevant information as part of the genitourinary assessment in the medical history. Later on if more detail concerning the patient's past social, occupational, and sexual history is needed it can be asked.
These last issues again raise the question of devising effective surveys for patients or their families to complete and then having the nurse review the completed forms and ask relevant clarification questions as opposed to having a nurse take a complete history in person. First, such a process eliminates certain obstacles that can arise during a lengthy interview such as poor rapport or miscommunication. Patients and their relatives understand the need to give such information and often readily complete them. Third, surveys and checklists take the burden off both patient and nurse with regards to answering sensitive questions as well as the prospect of someone overhearing personal information. Fourth, of course such a method saves time for both the patient and the nurse as a nurse can administer several surveys to patients and then complete them as the patients complete them. The use of such surveys should not be considered an excuse for nurses or other assessors not to know what information should be taken when getting an adequate patient history or how to ask questions and develop rapport, but should be used as a device to improve efficiency. Nurses, physicians, and other health care workers should still be trained in the methods of obtaining a patient history. There is actually some research to indicate that the use of comprehensive surveys and checklists followed by trained clarification interviews results in more accurate patient histories being taken than either one alone (Bickley & Szilagyi, 2007). The key is of course to have nurses who are trained to review the forms and ask the pertinent questions. Moreover, there may be situations where the patient is unable to complete a written survey and nurses can use the survey as a form of structured interview.
There is one other crucial element that is missing from the Craig synopsis that should be included with every history, a basic mental status assessment. Craig does not even approach this topic; however, it is crucial when asking any patient questions regarding their history to include basic mental status information. Such information can help to validate or invalidate the…