Chamberlain College of Nursing NR 305
Instructor Ludella Brown
Spring B 2012
Journal Article Review
‘A guide to taking a patient’s history’ is an article published in the Nursing Standard Journal, volume 22, issue 13, dated December 5, 2007, written by Hillary Lloyd and Stephen Craig. In this article, Lloyd and Craig describe the most effective and professional way to take a history from a patient in a variety of settings and the strategic reasons why doing so will achieve the best results. Summary of Article
Hillary Lloyd works for City Hospitals Sunderland NHS Foundation Trust, Sunderland and Stephen Craig works for Northumbria University, Newcastle upon Tyne, and both are senior nursing lecturers in the area of history taking and nursing assessment (Lloyd & Craig, 2007 p. 42). In this article, Lloyd and Craig explain how using a systematic approach to taking a patients history can be done precisely and professionally and will gain the most accurate record from the patient. Preparing the environment, communication styles, obtaining consent and history-taking process are the major components in the sequence of questions the patient is asked throughout the interview (Lloyd & Craig, 2007 p. 42-44). Taking a patient’s history will happen in all types of situations and in all kinds of environments. For these reasons, there is some “set-up” that needs to take place before the interview can begin. The nurse needs to make sure that the patient is as comfortable as possible, both physically and mentally. The nurse should also attempt to make the room free of distractions to ensure that the patient has adequate time to answer questions and no information is missed. The nurse needs to try, to the best of her ability, to give the patient respect and dignity no matter what environment they are in. This will enable the patient to trust the nurse which will ensure that even the most delicate of topics are talked about. One of the most important steps before the interview can begin is getting consent from the patient. Laws governing HIPPA and patient confidentiality are major legal issues in hospitals today. (Lloyd & Craig, 2007 p. 42). The history-taking process starts with good effective communication. By using proper introductions, maintaining order and structure, using open-ended questioning and using clarification, a nurse can obtain much needed information in a short amount of time. It is identified in both nursing and medical texts that a systemic approach to the interview will warrant the best results. Open-ended questioning is essential to a successful interview and enables the patient to tell their “story”. Closed questioning, for instance, “Is the blood bright red or dark red” provides key elements to the patient’s account. Clarification involves repeating back to the patient their story, in their own words, to check that what was heard is accurate and to correct any information that was misheard or omitted (Lloyd & Craig 2007 p. 43). The actual history-taking sequence is a step-by-step checklist that a nurse can follow from beginning to end and it covers all important or “cardinal” symptoms associated with each body system. In following these steps, a nurse can be sure that any potential problems are red-flagged to show symptoms which may need to be investigated further. These steps include the presenting complaint, any past medical history, mental health issues, medication history, family history, social history, sexual history, occupational history, systemic enquiry, further information from a third party and summary” (Lloyd & Craig 2007 p. 43). Presenting complaint is usually always the very first question that anyone asks a patient and it needs to be an open-ended question. The patient needs to be able to give there “story”, in their own words and then, when the patient is finished, the nurse can go back to the...