Taking a Patient's History

"A Guide to Taking a Patient's History” is an article published in an August 24th, 2007 issue of Nursing Standard. Written by H. Lloyd and S. Craig, the process of taking a history from a patient is outlined. Many aspects pertinent to obtaining a sufficient health history are discussed. In addition to providing a framework for completing a thorough health history, guidelines and interview techniques are explored.

Summary of Article

Obtaining a thorough health history is an important piece of a patient’s assessment. Failure to obtain a complete health history results in a lack of information that can negatively impact the patient. Interviewing skills develop through experience and practice. A complete health assessment involves several features and is a systematic process that involves respect, professionalism, and communication skills.

The first part of the history-taking process is creating an appropriate environment. Ideally, the interview takes place in an area that is safe, accessible, and free from distractions and interruptions. During this initial process, the interviewer introduces themselves and states their purpose and obtains consent to proceed with the health history interview. Additionally, the initial part of the interview is the time to establish the patient’s identity, age, and preferred way of being addressed. A relationship built on trust and respect for the patient’s privacy is necessary to developing a good rapport. It is important to remain unbiased and professional and furthermore, to treat the client with dignity. After introductions are made, the patient should be given time to tell their story in their own words. Active listening is a must during this interaction and involves both verba...

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...or in depth analysis of symptoms.

Key words such as closed and open questions are very well explained. Differentiating when to use each type of question is described and useful for facilitating an interactive dialogue. It is important to understand how to assist the patient in relaying important details and to ensure that what the patient has expressed is understood.

Conclusion

“The history-taking interview should be of high quality and must be accurately recorded” (Craig & Lloyd, p.48). It is important that while obtaining a thorough health history, that the patient is treated with dignity and that their privacy is respected. A complete history involves the collection of physical and psychosocial aspects of one’s health.

Works Cited

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