Taking a Patient History: Process, Skills, and Best Practices

Introduction to Patient History

A patient's medical history is a crucial first step in the appropriate evaluation of any individual seeking care. It consists of a structured set of questions posed to the patient — or to those who know the patient well — with the intent of obtaining data useful in formulating a diagnosis and providing quality, appropriate medical care. Within this step, the clinician must be diligent about following a checklist or system to ensure that all information relevant to clinical diagnosis is gathered.

Medical complaints reported by the patient are called symptoms, while clinical signs are observations described by medical personnel during examination. Within the broader framework of a medical history, the level of detail required varies by circumstance. A paramedic, for instance, might limit attention to critical information about drug interactions or allergies; a general practitioner would want a more detailed personal and family history to form a comprehensive profile; and a psychiatric history is typically quite long and detailed, serving as a template for a management plan (Tierney and Henderson, 2005).

The information obtained from a medical history is important in all clinical settings, particularly when the patient is in a new or emergency situation. Together with a physical examination, the medical history allows medical staff to form both a diagnosis and a treatment plan, or to make a provisional diagnosis and refer to a specialist or order tests to clarify findings. It is also important to recognize that patients will be at varying degrees of comfort and may not ask appropriate questions or volunteer private information spontaneously. For this reason, the medical history must be thorough yet sensitive. Research shows that patients may at times be more comfortable sharing personal information with a nurse rather than a doctor, or with a new medical professional rather than their regular GP (Why Patient's Don't, 2011).

Summary of Lloyd and Craig's Framework

The process of taking a patient history is critical within the broader framework of medical examination and diagnosis. Lloyd and Craig (2007) present a clear outline of this process, addressing preparation and control of the environment, the importance of clear and concise communication, and the value of a systematic, rational approach to gathering patient information. Lloyd is an instructor in nursing practice and Craig is an instructor at a university; both bring years of clinical and practical knowledge to the profession. The article is designed as both an instructional guide for new nurses and a refresher for more experienced medical personnel.

The authors argue that the proper approach to the patient's history is one of the most critical aspects of the modern medical paradigm. It allows the patient to express their own perspective while helping the medical professional focus on more targeted symptomology. The modern nurse's role has expanded greatly in response to numerous factors — staffing demands, advances in knowledge, and rising professional expectations — making a detailed, clinically informed medical history an increasingly important part of nursing practice.

The Five-Step History Process

The article outlines a basic five-step process for taking the medical history:

The Environment. This aspect is often neglected by medical professionals who are comfortable in a clinical setting. The patient, however — unless in an emergency — needs to be in a quiet and private space that respects both personal values and confidentiality. The medical professional should appear calm, focused, and respectful (Lloyd and Craig, 2007, p. 42).

Communication. Open and honest communication is vital if the medical history is to have any validity. Without truthful answers, an accurate diagnosis cannot be made. Exceptional communication skills are therefore essential — including both speaking and active listening — and non-verbal or body language cues should be managed appropriately. Medical jargon and technical terms should be minimized, and open-ended questioning techniques used to encourage disclosure. When a language barrier is identified, it should be addressed through the use of a family member or a professional interpreter (p. 43).

Consent. Informed consent is an important part of modern medical ethics. Rather than assuming a paternalistic stance in which patients are expected to comply without question, current regulations in most countries require that the patient has the ability to give or withhold consent — reflected in legislation such as HIPAA in the United States and the Mental Capacity Act in Great Britain. The patient's capacity to understand the process is also critical to obtaining reliable information (p. 43).

The Process. While the specific process may vary from institution to institution, a thorough history should include: the patient's current complaint, past medical history, mental health background, medication history, family history, social and sexual history, occupational history, inquiry based on previous answers, and relevant information from a family member or other pertinent individual (p. 43).

Follow-Up. Summation and follow-up are individualized based on the information received. A patient may not mention an issue that seems obvious, or may gloss over certain medications or lifestyle factors. Appropriate follow-up and verification are therefore necessary, as is flagging relevant concerns for other members of the medical team (pp. 44–45).

Conclusion

As a basis for understanding the process of the medical history, this article serves as an ideal introduction and review of the rationale and procedure involved. The authors conclude that the best method of achieving appropriate levels of skill is to use training and peer-review scenarios (Lloyd and Craig, 2007, p. 48). Of particular value is the set of references provided, which allows the interested reader to pursue further study in the research literature. While the article is oriented primarily toward standards in Great Britain, the information and organizational framework presented are global in both interest and applicability. If a medical professional applies the suggestions and material in this article effectively, the resulting medical history will be complete, current, detailed, and appropriate for all levels of clinical medicine.

References

Lloyd, H., & Craig, S. (2007). A guide to taking a patient's history. Nursing Standard, 22(13), 42–48.

Tierney, L., & Henderson, M. (2005). The patient history: Evidence-based approach. McGraw-Hill.

Why patient's don't ask questions, and what can we do? (2011). Medscape Today. Retrieved from http://www.medscape.com/viewarticle/743689_3