Journal Review of a Guide to Taking a Patient's History
Introduction “A guide to taking a patient’s history,” is an article published in Nursing Standard in December 2007, written by Hillary Lloyd and Stephen Craig. The article provides an overview of the process involved in taking a patient history including factors such as; the environment, importance of following a logical order when taking the history, and communication skills.
Summary of Article This article focused on the importance of taking a comprehensive health history and pointed out that this task is increasingly being undertaken by nurses. The article proposed that taking a logical, systematic approach when taking a patient’s health history allows for the most comprehensive collection of information. The article identified the Calgary Cambridge framework as a model for use during the interview process and stated that it is helpful for both new and seasoned nurses. It provides five suggested stages to implement during the interview process which include; explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation (Lloyd & Craig, 2007, p.44) One of the first things that should be considered when taking a history is the environment, as patients may be encountered in various environments. The article pointed out that safety must be considered, as well as respect for patient privacy. When beginning a patient history the nurse should provide an introduction to the patient and an explanation of the purpose of the interview. The patient must then give consent for the interview to proceed and must demonstrate they have a clear understanding of what they are consenting to. Once consent is obtained the nurse begins gathering information, asking open ended questions such as, “What are you experiencing?” which allows the patient to explain in their own words what is going on at the present time. After the patient has had the opportunity
Summary of Article This article focused on the importance of taking a comprehensive health history and pointed out that this task is increasingly being undertaken by nurses. The article proposed that taking a logical, systematic approach when taking a patient’s health history allows for the most comprehensive collection of information. The article identified the Calgary Cambridge framework as a model for use during the interview process and stated that it is helpful for both new and seasoned nurses. It provides five suggested stages to implement during the interview process which include; explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation (Lloyd & Craig, 2007, p.44) One of the first things that should be considered when taking a history is the environment, as patients may be encountered in various environments. The article pointed out that safety must be considered, as well as respect for patient privacy. When beginning a patient history the nurse should provide an introduction to the patient and an explanation of the purpose of the interview. The patient must then give consent for the interview to proceed and must demonstrate they have a clear understanding of what they are consenting to. Once consent is obtained the nurse begins gathering information, asking open ended questions such as, “What are you experiencing?” which allows the patient to explain in their own words what is going on at the present time. After the patient has had the opportunity
References: Lloyd, H., & Craig. S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13), 42-48.