Review of “A Guide to Taking a Patient’s History”

Introduction:

Published in 2007 in Nursing Standard (volume 22, issue 13, pages 42-48), and written by H. Lloyd and S. Craig, “A guide to taking a patient’s history, Clinical skills: 28” outlines the proper technique a nurse must have when setting out to gather patient history information.

Summary of the Article:

The focus of this article is to equip nurses with a practical guide to taking a patient's health history. It does that through the utilization of systems. By using a systems approach, the authors claim that the inherent organization allows for a more thorough gathering of pertinent patient information. The article begins by outlining the importance of environment. The space must be fully equipped, private, and safe. The patient needs to feel respected, which requires that the nurse maintains an air of non-judgment, get their consent, and allow for ample time to gather history. Craig and Lloyd go on to discuss the importance of communication and outline verbal and non-verbal communication skills, such as eye contact and pitch. This allows for a trusting rapport to be built between the patient and nurse and makes it easier for the nurse to transition into asking intimate, but necessary information. Open questions need to be asked first in order to get the broad scope of the problem. The nurse should then transition to closed questions to provide enhanced detail and clarification of the issue the patient is dealing with. All of the questionings need to work towards gathering information on a specific list of items (i.e. presenting complaint, mental health, and family history), and be performed in a systemic manner to ensure that all information has been gathered.

Craig and Lloyd focus on the Calgary Cambridge framework for gathering patient history. They believe that this method is best for both the novice and expert nurse. This plan of action has five stages: Explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation. They stress focusing on symptoms and not a diagnosis. If a nurse were to go through the patient history items listed in the article, they would need to approach each section specifically and individually. The presenting complaint required open questions, including questions about frequency and associated symptoms. The past medical history requires that you gather diagnosis, dates, sequence, and management. Mental health was noted as a difficult topic to broach, but one that shouldn’t be avoided. Medication history requires the nurse to find out both current and past medications taken, as well as the patient's concordance with their medication. This can have implications for the patient's future prescribed medication (i.e. allergies). Family history can reveal genetic predispositions towards certain diseases, while social history can reveal the patient's ability to cope with their health. Social history also includes the discussion of drug and alcohol abuse. The nurse should use the CAGE system when asking about alcohol intake, as it will reveal the level of dependency. When asking about alcohol, tobacco, and drug use, it was noted that it is important to keep things specific. Sexual history needs to be approached sensitively. Lloyd and Cage also stated that sexual history doesn’t always need to be taken. It includes questions like date of last menarche, pregnancies, infections, and libido. Occupational history is important because, it not only reveals job-related medical issues, but it also allows insight into patient financial stability. Finally, systemic inquiry requires the nurse to ask about the other body systems not related to the presenting complaint. It was noted that if an issue is brought up with another body system, then that should be looked into using the same methods as the first complaint.

Evaluation of the Article:

This article was very thorough. Craig and Lloyd’s focus on a systemic approach allowed for a complete and organized evaluation of taking a patient’s history. It would have been helpful for them to include more examples of the types of questions and statements that should be made and avoided during the interview process.

The article was of great interest. It provided concise directions on how to take a patient’s history, which is helpful information for the novice nurse. By creating this systemic approach, Craig and Lloyd virtually eliminated mistakes in the history-taking process. If one were to use this article to guide their history taking every time, I doubt that incomplete histories would be taken very often.

The comprehensive health assessment strategy is definitely beneficial. It provides step-by-step instructions to taking a patient’s history, which in turn, cuts down on the instances of incomplete histories due to unorganized note-taking. By adopting this into my practice, I would be able to be thorough and organized enough to arrive at a proper diagnosis.

The health assessment strategy was explained very clearly. By breaking down each element of the necessary information for patient history, this strategy ensured a clear understanding of the systemic approach it was endorsing.

While I feel that this particular subject has been well researched, and this particular method to be efficient, it is never safe to say that research should be closed to one particular area. The mantra, “if it ain’t broke, don’t fix it” does not really apply to the medical field, especially regarding human interaction. Medicine is an art and a science, which requires a constant reassessment of methods for continued progress.

This article has the potential to benefit a nurse at any stage of her career. The novice nurse would do well to follow the directions outlined in this article, as it would lead to the formation of healthy habits regarding taking health assessments. The seasoned nurse would also do well to study Craig and Lloyd’s article. It could provide a refresher in proper technique and reinvigorate the history-taking process to ensure accuracy and avoid complacency due to repetition.

Conclusion:

Craig and Lloyd focused on a systemic approach to patient health assessment. By outlining a specific method, they took what could be a disorganized process, and distilled it into an organized and easy task. By utilizing their method, the nurse ensures that the patient history is thorough and taken properly. In the end, gathering this type of information at that level of organization helps to ensure a proper diagnosis and treatment for the patient.

Reference

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