NR305 Health Assessment
Alexis M. Schoolcraft
Chamberlain College of Nursing
Dr. T. Williams
Winter B 2014
Introduction
Patient’s history is undoubtedly one of the most important sources of medical information and, if conducted properly, may be quite useful. The article “A guide to take a patient’s history” written by Hilary Lloyd (a principal lecturer in nursing practice, development and research at City Hospitals Sunderland NHS Foundation Trust, Sunderland) and Stephen Craig (a senior lecturer in nursing at Northumbria University, Newcastle upon Tyne) was published in the official UK medical journal Nursing Standard in 2007 and is a very descriptive and vivid source of information about respective techniques and their practical application.
Summary of the Article
The article is positioned by the authors as a framework of the process of taking a patient’s history. From the structural point of view the piece of writing consists of several parts.
In the introduction the authors underline the significance of patient’s history as a significant source of medical information available not only to doctors, but also to nurses and combinable with other assessing methods. The growing importance of this method is also being stressed.
The rest of the article is composed of the specific data concerning preparing the environment for the procedure of taking a patient’s history (e.g. securing space in which it is supposed to take place, providing sufficient time, care and respect for the patient in order to gain her or his trust and obtain the most detailed and comprehensive information), establishing proper communication with the respondent using specific verbal and non-verbal methods as well as simple language, often rephrasing patient’s own words so as to reach mutual trust and understanding. It is then recommended to gain informed and willing consent of the patient to carry on with respective questioning, as the history may contain issues of quite delicate nature, and the patient must be aware of the possible issues regarding those and their consequences of both medical and legal nature.
The article presents detailed description of the range of questions that are supposed to be asked during the process of taking a patient’s history and their precise order. The procedure should start with a brief introduction of the process, its reason and impact on patient’s further medical treatment. Upon that there has to be a train of questions from present complaint, past medical history, mental health and medication history to highly delicate issues of family, social, sexual and occupational history, concluded by systemic enquiry (questions about functioning of other systems of a patient’s body, even if those are not relevant to the current complaint).
Apart from detailed description of each group of these questions and several qualitative and quantitative indicators which can be used in evaluation of respective answers, the article also provides valuable tips concerning the psychological aspects of the questioning process. The process of gathering information should, according to the authors, start with open-ended questions of more general nature, which would allow patients to share their point of view on their health issues and provide nurses with data for further, more specific close questions, addressing and clarifying certain particular moments and helping the medical personnel to summarize the case. It is obvious that this is only achievable by working close with the patients and cooperating with them instead of merely interrogating them. In order to do so and reach the maximum efficiency within limited time, Calgary-Cambridge Framework is described, which includes such elements as explanation and cooperative planning, aiding recall and shared understanding, shared decision-making etc.
The article concludes with a statement that all the information provided in it may and should be used for practical purposes, and its validity has been verified throughout various field experiments.
Evaluation of the Article
The article is indeed an interesting and practical one. It has several undoubted advantages. First of all, it is written in a professional, yet quite understandable language. The authors themselves applied the principle of avoiding overcomplicated professional jargon in order to reach understanding of the target audience. The article also contains a multi-disciplinary approach to the problem of taking of patient’s history. Apart from psychological tips, it offers a detailed list of methodological points as well as specific medical indicators, therefore presenting the topic in all its complexity. Finally, the way that information is organized within the narration, respective bullet points and charts allow readers to comprehend most of it in a timely and efficient manner.
On the other hand, there are also certain ways in which the content of the article might be improved. Although it is clear that the authors tried, and not without success, to develop a universal framework for the procedure, real-life conditions, especially at the hospital, are usually both stressful and quite specific, so it would be reasonable to pay some attention to extreme situations and how the framework could react at and adopt to them. Besides that, the whole article appears to be somewhat shallow and vague. Each major element of the process is mentioned and briefly described, but more specific examples would be very useful in order to demonstrate the effectiveness of the method which is being promoted by the authors. Finally, although the procedure allows to evaluate a patient’s condition, there is no tool mentioned which would allow to evaluate the procedure itself and determine its potential and future within the system of medical care in general. These are the main critical points that may be improved.
Despite several loopholes, the article appeared to be interesting and easy to read. It is doubtful that its content got obsolete even after 7 years since publication. The techniques offered in it appear to be both technically adoptable and convenient, yet to be more specific and need-based in every given case. The strategy of taking a patient’s history was explained in a relatively clear manner, yet there is no doubt that more specific research has to be made in this regard. Effective adoption of this framework may be useful for all the stakeholders, including both hospitals and general public, saving time, resources and lives, respectively. It may signify the beginning of the new era of interaction between medical staff and patients – the era of effective mutual communication and shared decision-making.
Conclusion
The article, although published several years ago, may still be quite influential by nature not just in the UK, but also worldwide. The research made by the authors, although not entirely comprehensive and flawless, is based on more than 25 academic sources and should not be underestimated. There is a reason to believe that, if properly developed and localized, the framework and respective strategy may be of significant positive influence on the national and global medical community both in the short and long run.
References:
Lloyd, H., and Craig, S.(2007). A guide to taking a patient’s history. Nursing Standard, Vol.22, 1111111No.13(2007), p.42-48.
