Taking a patient's history: a clinical guide

¶ … Patient's History

History taking is a very crucial subject when it comes to taking proper care of the patient. Because it is so important, it requires in depth research and knowledge about the subject. The article that would be discussed today is called A guide to taking a patient's history. The author of the article is Lloyd H. Craig. Published in the journal Nursing Standard, the article was accepted August 24th, 2007.

The focus of the article is on the importance of history taking and how the procedure should be carried out. First and foremost, the relevance of history taking is mentioned. It should be noted that giving history is the first communication and interaction that the patient will have with their health care worker. (Crumbie, 2006) A lot of nurses are now expanding their approach towards the patient. (Lloyd & Craig, 2007) A major step in the history taking process is ensuring a proper environment and the consent of the patient. A nurse should take extra care to maintain a comfortable and confidential environment for the patient. Most of the patients are reluctant to give out their personal details and a peaceful environment will give them the push to have their information flowing. The next important step is taking the consent from the patient and having them easily respond to all the questions.

A major point in history taking is that every little detail matters. Many patients might not provide some information and thus can lead to a poor treatment in the long run. Ensuring the patient's consent and giving them proof of the confidentially of their information will make this entire process easier. The communication that is created between the nurse and the patient should be quite comprehensive. (Crumbie, 2006) The nurse should make sure that the patient is presented with open and closed questions. Open questions are preferred more because they enable the patient to give more information and keep going with the details.

The history taking process itself consists of many components but starts off with the presenting complaint. A patient might have a lot of medical problems at a given time but usually the most problematic ones compel the patient to visit the doctor. A nurse's first objective is to gather that presenting complaint and then work ahead with that. Subsequent to giving all the information about the presenting complaint, the patient is inquired about his or her past medical history. Now this is important because it can lead to a cumulative diagnosis or help with what the patient might have been through. In past medical history, concurrent diseases such as hypertension and diabetes are also mentioned. A major component of patients is mental health. This gives the nurse an idea of what events or mishaps the patient has been through.

Now that the health care worker has covered the present complaint and the mental problems, detailed history regarding the medications is taken. Taking history about current medical allergies is very important as a wrongly prescribed drug can lead to severe adverse effects. Family and social history is also considered to look at certain risk factors for possible diseases that the patient could have. This brings us to the next step in the history taking process which is sexual history. As it would be expected, this is quite a sensitive area and a very difficult one to approach. Even though sexual history informs about endocrine abnormalities and possible exposure to sexually transmitted diseases, it is not appropriate to take a detailed sexual history. (Dougias et. al, 2005) Subsequent to that, one should inquire about the occupational history. The history is concluded with taking a general systemic inquiry about all the body systems. These questions are not related to the presenting complaint and they briefly inquire about the other body systems.

Critique

The article was written quite comprehensively and gave enough information about the different aspects of history taking. The way all the different components of the history taking process were split up and explained in more detail was very helpful. It was noted that the entire information in this article was present in a rather organized way. This organized way of presenting the details helped in teaching the history taking process and left less ambiguity. One thing that could have been improved is that common mistakes in the history taking process should have been mentioned. Surely with the amount of research done on this topic, the common mistakes and questions would have been figured out. If the commonly made errors are highlighted in these articles, then those errors are less likely to be repeated by other nurses as well.

This article did interest me as it provided me with a good layout for history taking. A major thing that interested me is how the authors provided the rationale for every single step. Reading about the logic and rationale behind a step alarmed me about its importance. Therefore, now I would make sure to not miss out that step.

The health assessment strategy was quite beneficial as it told me about the important steps required to completely assess a person's health. Prior to reading this article, there are many steps that I didn't know were included in a health assessment. I can most definitely adopt this strategy in my practice and I feel that the explanation was enough for me to get a hold of all the important areas. I do admit that I would like to read more about certain parts of the history taking process and that's why I think more research articles should be written on this topic. In my opinion, this article would benefit health care workers such as nurses or doctors. In my opinion, patient's primary interaction does occur with a nurse. A nurse should be well trained in how to deal with the patient so that a healthy relationship can be started with the patient.