Patient History Taking: A Critique of Craig's Nursing Guide

Introduction: The Importance of Patient History Taking

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 an unsatisfactory one. However, taking a complete and useful history is a skill developed through training and practice; it is not an innate talent (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 clear guidelines for obtaining 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 to most patient populations; however, Craig does not address certain cultural issues that could be important in obtaining an accurate and complete history, especially when discussing sexual issues, psychiatric concerns, and other aspects of a patient's background that might create cultural tensions. Alarcón (2009) offers some insights into how to handle these issues. That notwithstanding, Craig provides very useful information regarding how to take a complete patient history.

Craig's Approach to the Interview Environment and Rapport

Craig (2007) begins by discussing issues that many other articles on this topic overlook or perhaps take for granted, despite their importance in completing an accurate patient history. For instance, Craig rightly points out that the environment in which the history is taken should be safe and private, allowing the patient to feel at ease when providing information. Craig emphasizes the importance of early rapport-building through genuine concern, proper self-introduction, and explaining the purpose of the upcoming questions before beginning the actual assessment.

Moreover, Craig stresses that the nurse-assessor should be a good listener, allowing patients or family members to relay information at their own pace, and should remain non-judgmental regarding the information shared. Simply attending to these factors will often result in patients or their relatives revealing information they would not otherwise disclose without specific prompting (McKenna et al., 2011).

Although Craig outlines a specific order in which to take the patient's history, he does not believe that strict adherence to that order is necessary. In a sense this may be true; however, following a consistent order may also safeguard against omitting important information or losing one's place in the interview process if an interruption occurs (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.

Questioning Strategy and Structure of the History

The most important issue should be the first question asked, which is, of course, an inquiry about the presenting complaint (Alarcón, 2009). Craig lists a helpful series of questions that can be crucial in filtering out useful information regarding the presenting problem. These could easily be converted into a mini-checklist or structured format following the open-ended, closed, and clarification sequence described above. Following a complete inquiry into the presenting complaint, the assessor should then proceed to the prior medical history, again using the open–closed–clarification method.

Often, patients fill out forms listing previous medical conditions, which can serve as a useful guide and time-saving device — something Craig does not mention. To avoid redundancy and save time, nurses need to be able to read these forms quickly, identify what additional information is needed based on patient responses, and record important details accordingly. Craig provides a useful list of symptoms (Box 4, p. 45) that could serve as a symptom check-off list in settings that do not use structured intake forms. A number of texts and papers also provide comprehensive lists for 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 the importance of obtaining a thorough medication history, mental health history, family medical history, social and sexual history, and substance use profile, and provides sufficient guidance for gathering relevant information across these domains. The medication history, family medical history, and mental health history are clearly crucial. Some practitioners may not initially view the patient's full social, occupational, and sexual history as essential in every context; depending on the presenting complaint, this may be a reasonable position. However, certain aspects of a patient's social history — for example, whether the patient is married — are always relevant. In terms of occupational and educational background, it may initially be sufficient to ask a few targeted questions, such as whether the patient is employed, what kind of work they do, and their highest completed level of education. Such information can provide useful clues about how to communicate with the patient, the patient's level of understanding, and the patient's support network.

Regarding sexual history, this is a sensitive area in many clinical contexts, and it may be more practical to ask relevant questions as part of the genitourinary assessment within the medical history review. More detailed social, occupational, and sexual history information can be gathered later if needed.