¶ … 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...
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…
