Introduction
It is important to take the patient history. Nurses should take this history during assessment. When this is done, the patient’s problems are easily captured for the purpose of treatment. This has been made by nurses routinely. Roles of nurses are expanding with the new technology. They take information from patients, type it and make changes where necessary. Information from patients is private and confidential. Taking information from patients requires a practitioner or a specialist, nurse. In addition, taking the history is a fraction of assessment made to the patient. There is a need to use other information gathering techniques. Assessment covers inquiry into the patient's needs. This is an interactive process.
Summary of the Article
Information from patients can be obtained while the patients are in various environments. Some of this scenery include; care centers, clinics, emergency and accidents and patient's home. The term environment here refers to an accessible, distraction free, safe and equipped appropriately. The assessor should be aware of the patient's culture to observe dignity and uphold respect. During the assessment, the nurse should not be conclusive. Observing respect is vital during the assessment. It entails dignity and privacy. This must be adhered to. When taking history, the nurse should give enough time for each piece of information the patient is providing to enhance the patient's care. The process of information gathering requires good communication skills. Moreover, it should be professional, sensitive and in a systematic manner. The professional procedure which is usually applied starts with an introduction. Nurses should give a chance to the patient to give the history in their own words. Active listening is important to the side of the nurse. It is required that the nurse and the patient be relaxed during this time. As usual, a rapport has to be initiated. Technical terms should be avoided. When using such terms, communication between the nurse and the patient is barred. Not all people are exposed medical terms.
The inquiry into the patient's problems needs short and vivid questions. Nothing is left out. This applies to the practitioners. The various questions used include; closed and open ended questions. Closed questions make the history of the patient clear and detailed. Open-ended questions are the most applicable. These questions help in gathering information that is not orderly. Every question should be structured so that it does not hurt the patient in the process of gathering information. Sometimes one can write down the questions to be asked so that all important areas are covered.
The success of the assessment depends on the clarity of the nurse. Clarification entails going through the history gathered with the patient. When this is done, corrections are made where necessary and the right information in obtained. After a full assessment has been made, the nurse should ask is there is something else left out which can be used during treatment. One develops assessment skills with time in the profession. The whole exercise needs; reflection, discussion focusing, encouraging participation, offering leads, making observations, clarifying and summarizing.
The first step during history taking is presenting a complaint. Mostly the question about problem is asked. Procedurally, the next thing of inquiry is that concerning the signs. One should concentrate on the symptoms and not the diagnosis. After the patient has highlighted the symptom, the nurse should explore all the cardinal symptoms in the symptom reference book. Questions about the chest, ankle swelling, breathlessness, lower leg pain and breathlessness are used gather details. There is a need to enquire about the; onset, duration, radiation and site, relieving features and aggravation, symptoms associated and frequency.
Information that should be captured during this process includes; diagnosis, dates, sequence and management. During this step, direct questions should be used. An inquiry into the predisposing to common diseases such as Tb, asthma, fever, hypertension, heart diseases and diabetes should be made. Information concerning mental health assessment requires professionalism. To start with, the professional must ask questions pertaining anxieties and mental health issues such as schizophrenia and bipolar disorder.
When searching medication history, several considerations have to be made. Some of these are the medication taken, medications bought at the pharmacy or supermarket, name of a medication, decrease or increase of dose and the frequency of taking the medication. The nurse should find out the level of concordance with medication. Moreover, the nurse should ask about allergies and other symptoms that can help in the diagnosis.
History of the family provides hereditary information. Such information includes; cerebral disease and dementia history. Closed and openly ended questions should be applied. Question about the susceptibility of family members to various diseases should be asked. In addition, the treatment of those diseases should be asked.
Social history is another assessment has to be conducted. What the patient does on a daily basis is to be known. This entails; leisure, household chores and other tasks. In conjunction to this, the marital status of the patient should be asked. An inquiry into the housing of the patient gives the nurse the clue on the living standards and hygiene. Other factors that the nurse should consider when collecting social history include; the use of drugs and material abuse. This helps gather information about the possible reasons behind patient’s disease. Moreover, the nurse should also ask questions concerning the patient’s occupation. This includes the history about the past and the present employment. Some occupations expose employees to radiations and respiratory problems. In addition, occupation history also provides information about the financial status of the family.
Finally, systemic history should be taken. This involves asking questions on all areas not covered during the interview. Similarly, it is important because it ensures that there is no information omitted.
Evaluation of the Article
The guidelines discussed in the article are crucial in recording a patient’s history. It provides a clear and procedural manner of obtaining information from the patient before diagnosis and treatment. The article outlines relevant content for medical practitioners. Further, it highlights medical, family, social and the occupational history which is vital before diagnosis and treatment of the patients. It is very useful. Moreover, the author is an expert in this field. In the article, the author uses references and to a great extent the content is up-to-date.
Conclusion
The article highlights key points in history taking. The medical practitioners need to integrate the facts discussed in the article in their daily practice. Some of these include; environment preparation and communication skills. History taking should be recorded and must be of high quality. To sum up, the study has elucidated the guide to history taking.
References
Henderson, M. C., Tierney, L. M., & Smetana, G. W. (2012). The patient history: An evidence-based approach to differential diagnosis. New York: McGraw-Hill Medical.
Hohler, S. E. (2008). Arthritis: A patient's guide. Jefferson, N.C: McFarland & Co.
Lloyd, H., & Craig, S. (2007). A Guide to Taking a Patient's History Clinical Skills. Nursing Standard, 22(13), 42-48.
