¶ … Patient's History
The expanding roles that nurses play in the healthcare field include taking the health history of patients. There are many important components to the task of taking patient histories, and this paper reviews those important aspects and components that are published in the Nursing Standard article by Lloyd H. Craig.
Craig says taking the history of patients is "…arguably the most important aspect of patient assessment" (Craig, 2007, p. 42). The reason it is so vital to the practitioner (or doctor) is that every healthcare issue or concern that the patient has encountered in his or her past -- recent or not -- may have implications for how the patient is to be treated.
Nurses do not always see the patient in a doctor's office or a hospital patient room. The nurse might encounter patients in the following environments, according to Craig: a) in an accident scene or an emergency room; b) in a general hospital ward; c) in "department areas"; d) in "primary care centres"; e) in healthcare clinics; and f) in the patient's home (Craig, 42).
No matter when the contact is made between nurse or patient, there must always be "…respect for the patient as an individual" which includes being open-minded (that is, "non-judgmental and professional") about the "beliefs and values" of the patient (Craig, 42). Part of the respect the nurse must show to patients at the time of taking histories has to do with the privacy that is provided during the process. It should be a quiet, dignified place, and the nurse must be given ample time to conduct the interview, Craig continues on page 42. Clearly the nurse already has good communication skills or he/she wouldn't be an RN in the first place, but Craig asserts that the patient must be given time to tell their story and the RN must be a good listener, to allow the story fully and without interruptions.
On page 43 Craig mentions an important part of the process which might have been alluded to earlier -- that is getting...
Part of that process is making sure that the patient is acting under his or own free will, and that they have a full understanding of what they are involved with.
The interview starts with an "open-ended" question, such as, "Tell me about your health problems," and perhaps follow up with this: "How does this affect you?" Once those questions have been answered, and the nurse has allowed the patient to tell his or her story, then it is time for closed questions. By this time the nurse has heard about the patient's health issues, and asking questions like, "When did this begin?" And "How long have you had it?" is appropriate as follow-ups to the initial verbal response of the patient (Craig, 43).
A good rule of thumb for the nurse is to take notes and then repeat back to the patient the salient points that the patient had made. This summary will check to see if the nurse got it correctly, and also it will give the patient an opportunity to expand on anything that was said earlier, Craig continues on page 43. Craig (p. 44) references the Calgary Cambridge Observation Guide (CCOG), a framework for the interview with patients. In that model (five stages) it is expected that at the conclusion of the initial interview there will be a kind of fact checking by the nurse to see that everything is correct.
The second stage is "making information easier for the patient using reflection"; the third is to achieve "…a shared understanding" of the patient's perspective so as to continue a two-way communication dynamic; the fourth stage from the CCOG is working with the patient "…to assist understanding" in the process (Craig, 44). And finally, the last phase of the CCOG is to offer the patient a good plan in order to meet the needs and the expectations of the patient. As he continues on page 44, Craig runs through the history-taking process again, with slightly different points and questions to be asked.
What is important for the nurse taking the…
