¶ … Patient's History
The medical history of a patient is a crucial first step for the appropriate evaluation of the patient. It is a list of questions given to the patient or people who known the patient well with the intent of obtaining data that is useful in formulating a diagnosis and providing quality and appropriate medical care to the individual. Within this crucial step, one must be diligent about following a checklist or system in order to ensure that one gleans the appropriate information to assist in clinical diagnosis. The medical relevant complaints from a patient, for instance are called symptoms. Clinical Signals or Clinical Signs, however, are different and are described by medical personnel examining the patient. Within the rubric of a medical history, however, there are various levels of detail necessary depending on the circumstances. For instance, a paramedic might limit detail to critical information about drug interaction or allergies; a General Practitioner would want a more detailed medical history of the individual and the family in order to form a profile; and in many cases, a psychiatric history is usually quite long and detailed in order to process a template for a management plan (Tierney and Henderson, 2005).
Thus, the information obtained by a medical history is important in all aspects, particularly when the patient is in a new or emergency clinical situation. Together with a clinical examination, the medical history allows the medical staff to form both a diagnosis and treatment plan, or to make a provisional diagnosis and call in a specialist or order tests to clarify the original diagnosis. In addition, it is important to note that within a medical situation, patients will be at varying degrees of comfort and may or may not ask appropriate questions, or volunteer private information. For this reason, it is especially important that the medical history be thorough, yet sensitive. Research shows that, at times, patients may be more comfortable sharing personal information with the Nurse rather than...
Lloyd and Craig (2007) presents a clear outline of the process of taking a patient history from preparation and control of the environment, the importance of clear and concise communication, and the importance of a system of order and rationale for what information should be in the history. Lloyd is an instructor in nursing practice at City Hospitals, Sunderland, Craig is an instructor at Northumbria University. Both bring years of clinical and practical knowledge to the profession and it is clear that the article is designed as both an instructional guide for nurses and a refresher for other medical personnel.
The authors believe that the proper approach to the patient's history is one of the most critical aspects of the modern medical paradigm. It allows the patient to discuss their own views while helping the medical professional key in to more focused symptomology. The modern nurse's role, of course, has expanded greatly based on numerous factors; staffing, knowledge, information, expertise, and expectation. Detailed medical history using even more clinical knowledge is thus an important part of the prevue of a modern professional nurse.
The article outlines a basic five step process to the medical history:
The Environment -- This is often neglected by medical professionals who are comfortable in a clinical environment. The patient, however, unless in an emergency situation, needs to be in a quiet and private space that considers both beliefs and values and confidentiality. The medical professional should be calm, not distracted, and show the patient respect (42).
Communication -- Open and honest communication is vital if the medical history is to have any validity. Without true answers, a proper diagnosis cannot be made. Exceptional communication skills…
