Patient\'s History Involves More Than

¶ … patient's history involves more than just asking a serious of questions. There is a lot that goes into this process that the nurse should be aware of. The patient's history is important because it lays the blueprint of how to diagnose the patient's illness based on the history given. Not all nurses are skilled in this area. It takes much more than medical expertise to perform this task. The nurse must be an excellent communicator which means speaking as well as listening. She must also respect the patient's privacy and ensure that confidentiality is always maintained (Lloyd and Craig, 2007).

Every patient is different and patients will always have their own type of communication style. The nurse must be receptive to this and deal with the patient's accordingly. Professionalism and friendliness is always a plus. The person taking the patient's history should always introduce herself and make the person feel at ease. Using technical or medical terms is usually not a good idea as the patient may get confused as to what is actually being asked (42). The patient's consent is especially important and the nurse must be aware of whether or not the patient is mentally capable of giving consent (43). If it is determined that the patient is not mentally capable, then a guardian may need to answer any questions and in the case of a minor, one or both parents or a legal guardian should be present at all times.

The process to taking the patient's history is something that should be taught to nurses before they complete nursing school. Many time nurses are taught all of the technical and medical aspects of the job, but are not taught how to effectively deal with the patients. As mentioned before, the nurse should always introduce herself at the beginning of the process. This is not only considered professional, but it also serves as an ice breaker. Knowing how to ask questions as well as what questions to ask is also important. Open ended questions allow the patient to tell the nurse what the exact medical issues are that they are having. Once the nurse takes down this important information, she can then begin with the close ended questions such as asking the patient how long they've had the particular problem (43).

When taking the patient's history, the nurse should always focus on the symptoms instead of the diagnosis. This falls in line with the list of cardinal symptoms which serve as a guideline of what to look for based on what type of symptoms the patient has (44). Each symptom that the patient reports should be carefully examined as it could lead to many underlying hidden medical issues.

Sometimes taking the patient's history can be uncomfortable for both the nurse and the patient. The patient may have a history of drug abuse or may have been sexually abused. The nurse must skillfully and tactfully answer these questions and may preface them by telling the patient that the questions she is about to ask may be a bit uncomfortable, but that she needs to ask in order to get an accurate medical history. Another way to put the patient at ease during moments like this is for the nurse to be absolutely certain that she is not showing any signs of being judgmental. If this happens, it could throw the patient off guard and create an uncomfortable situation where the patient no longer feels comfortable being honest with the nurse. Once this happens, the nurse will have an inaccurate patient history and the patient runs the risk of not being treated properly for the underlying symptoms.

In order for the history to be as accurate as possible, the nurse should ask questions regarding several issues that may affect the patient's health. The patient's past medical history is vitally important to the process because it can serve as a guide to what has worked in the past and what treatments are ineffective. The patient's mental health is also important. This will give the nurse any indications if the patient is not mentally stable. The state of mental health of the patient is important since it is now a known fact that a positive mental outlook does play a role in medical recovery (45).

The nurse should always ask the person about any medication he is taking. This includes prescription medication as well as over the counter. This is important in order to prevent any type of drug interactions. The patient's family history as well as social history is also important. The family history is important because many illnesses and diseases are genetic and passed down from generation to generation. The nurse needs to know this. The patient's social history is important because the nurse needs to know if the patient is capable of performing normal daily functions in the home without any assistance. The nurse also needs to know (in some cases) whether or not the patient has an active social live. Active social lives should never include excessive alcohol consumption as this could cause other serious medical problems for the patient (46).