A guide to taking a patient’s health history is an article published in Nursing Standard in the August 2007 issue, written by Hiliary Lloyd and Stephen Craig. In this article Lloyd and Craig outlines the process and rationale for taking a health history. Also, this article provides different methods to taking a comprehensive history.
Summary of Article
Taking a successful history includes preparing the environment, effective communication skills, and order. It is the most important part of patient assessment. In the process, patients are able to present vital information about their problem in their own words. To explore a decline in a patient’s health requires a careful evaluation of patient needs. To avoid receiving incomplete information, allowing adequate time is essential to complete the history. The environment should be assessed first for the safety of both the patient and nurse, have no distractions, be quiet, have the right equipment and be conducted in a private setting in order to maintain patient confidentiality. Cultural consideration is important to taking the history and creating a meaningful nurse-client relationship and should be performed in a professional, non-judgmental manner by performing a cultural assessment, because things like eye contact, handshakes, or posture may have different meanings in various cultures. It is also very important to assess health beliefs and practices since a person’s perceptions about health and illness are greatly influenced by one’s heritage and culture. After introducing yourself to the patient, maintaining good communication is critical. Patients must be allowed to tell the story their way while the nurse actively listens. This is a basic part of the communication process and is the most important interactive skill because it means paying undivided attention to what the patient says and does (D’Amico & Barbarito). The patient should not feel rushed as this could adversely affect building of...
References: D’Amico, D., Barbarito, C. (2007). Health & Physical Assessment in Nursing. Upper Saddle River, NJ
Douglas, G., Nicol F., Robertson, C. (2005). Macleod’s Clinical Examination. 11th Edition. Churchill Livingstone, Edinburgh.
Lloyd, H., Craig, S. (2007). A guide to taking a patient’s history. Nursing Standard. Retrieved 1/15/2011.
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