Patient\'s History the Expanding Roles That Nurses

¶ … Patient's History

The expanding roles that nurses play in the healthcare field include taking the health history of patients. There are many important components to the task of taking patient histories, and this paper reviews those important aspects and components that are published in the Nursing Standard article by Lloyd H. Craig.

Craig says taking the history of patients is "…arguably the most important aspect of patient assessment" (Craig, 2007, p. 42). The reason it is so vital to the practitioner (or doctor) is that every healthcare issue or concern that the patient has encountered in his or her past -- recent or not -- may have implications for how the patient is to be treated.

Nurses do not always see the patient in a doctor's office or a hospital patient room. The nurse might encounter patients in the following environments, according to Craig: a) in an accident scene or an emergency room; b) in a general hospital ward; c) in "department areas"; d) in "primary care centres"; e) in healthcare clinics; and f) in the patient's home (Craig, 42).

No matter when the contact is made between nurse or patient, there must always be "…respect for the patient as an individual" which includes being open-minded (that is, "non-judgmental and professional") about the "beliefs and values" of the patient (Craig, 42). Part of the respect the nurse must show to patients at the time of taking histories has to do with the privacy that is provided during the process. It should be a quiet, dignified place, and the nurse must be given ample time to conduct the interview, Craig continues on page 42. Clearly the nurse already has good communication skills or he/she wouldn't be an RN in the first place, but Craig asserts that the patient must be given time to tell their story and the RN must be a good listener, to allow the story fully and without interruptions.

On page 43 Craig mentions an important part of the process which might have been alluded to earlier -- that is getting the "informed consent" from the patient. Part of that process is making sure that the patient is acting under his or own free will, and that they have a full understanding of what they are involved with.

The interview starts with an "open-ended" question, such as, "Tell me about your health problems," and perhaps follow up with this: "How does this affect you?" Once those questions have been answered, and the nurse has allowed the patient to tell his or her story, then it is time for closed questions. By this time the nurse has heard about the patient's health issues, and asking questions like, "When did this begin?" And "How long have you had it?" is appropriate as follow-ups to the initial verbal response of the patient (Craig, 43).

A good rule of thumb for the nurse is to take notes and then repeat back to the patient the salient points that the patient had made. This summary will check to see if the nurse got it correctly, and also it will give the patient an opportunity to expand on anything that was said earlier, Craig continues on page 43. Craig (p. 44) references the Calgary Cambridge Observation Guide (CCOG), a framework for the interview with patients. In that model (five stages) it is expected that at the conclusion of the initial interview there will be a kind of fact checking by the nurse to see that everything is correct.

The second stage is "making information easier for the patient using reflection"; the third is to achieve "…a shared understanding" of the patient's perspective so as to continue a two-way communication dynamic; the fourth stage from the CCOG is working with the patient "…to assist understanding" in the process (Craig, 44). And finally, the last phase of the CCOG is to offer the patient a good plan in order to meet the needs and the expectations of the patient. As he continues on page 44, Craig runs through the history-taking process again, with slightly different points and questions to be asked.

What is important for the nurse taking the patient's history is to "…concentrate on symptoms and not on diagnosis," that way it can be certain the "no information is missed" (Craig, 44). In fact it is not the nurse's job to provide diagnosis. But when the patient says there are "palpitations," that gives the nurse the clue to proceed with specifics. Questions about the frequency of chest pains, about any trouble breathing the patient may have had, and questions about possible swelling and pain in the patient's lower legs are all relevant and should be addressed.

Regarding the palpitations, a question that has good value might be, "Was it sudden, or has it developed gradually?" Another might be, "How long does the sensation last… minutes, days, or weeks?" On page 45 Craig goes over the need to have the nurse capture a full account of the patient's history; this section is similar to the section on page 43, but goes a bit deeper. An example is the "social history" portion of the intake interview; "Nurses should consider the whole of the family when exploring a social history," Craig explains. In other words, if a patient apparently has a deteriorating health condition, is that patient still able to play sports or continue to engage in leisure activities? Asking those kinds of questions is helpful to a full accounting of the patient's health.

On page 47 Craig suggests that the nurse should inquire as to the work history of the patient. Did the patient work in a place where there were impurities in the air which may have contributed to respiratory problems or problems with the joint. A nurse should use tact and sensitivity in inquiring about a sexual history, Craig explains on page 47. But if it is appropriate to do so, a man should be asked -- as "part of the genitourinary system history" -- if he has had any sexually transmitted infections and treatments"; and a woman can be asked about sexually transmitted infections as well as "high-risk sexual activity" she may have engaged in.

Evaluation of the Article

This is a very thorough article, and it could be used as an assignment in a nurse's training program for a number of reasons. First, it touches all the bases regarding what is expected of a nurse when she is taking a patient's history. Secondly, it provides hands-on, step-by-step information on what a nurse should be doing in that environment. There certainly are textbooks that spell out the same procedures regarding the taking of a patient's history, but an article from a peer-reviewed publication is easier to grasp in a short period of time.