The Importance of Taking an Accurate Medical History

The Importance of Taking an Accurate Medical History

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“A guide to taking a patient history” is an article appeared in volume 22, issue 13 of the Nursing Standard Journal in December 2007 written by H. LLoyd and S. Craig. The article talks about the steps and strategies to follow when taking a patient history. It is important to acquire good techniques in assessing a patient starting by the environment, communication skills, and a systematic approach. One must be able to collect accurate data in order to facilitate the procedure.
The article starts by emphasizing on the environment when taking a patient history. The environment should be safe for both patient and nurse. The environment should be quiet and ideally, there should be no interruptions (LLoyd & Craig, 2007). For proper gathering of the patient’s history, the environment should be prepared well in advance.
One important issue identified in the article, is communication as a foundation in managing the process of history taking. In order for adequate communication to happen between the patient and the nurse, there must be sufficient interaction between the two. Both verbal and nonverbal skills are needed. Questions should not be judgmental. Open questions give more general information about the patient. Calgary Cambridge framework is one of the method that one utilizes. The nurse should treat the patient with respect and dignity and to do everything possible to retain confidentiality.
Moreover the patient needs time to provide a complete history. It is best to avoid technical terms that the patient may not be able to understand. It is important for the nurse to express herself clearly to avoid confusion. Before starting the process, patient consent is required. It is also important to ask the patient about health beliefs and practices.
Once the general structure of history is established, one can begin asking about presenting complaint, past medical history, mental health followed by medications history. It is important to find out about over the counter medications and herbal remedies that the patient is currently taking. Family history is also a good tool in taking patient history. The patient social history should also be included along sexual history and occupational activities. The nurse needs to gather information about the other systems in the body that are not covered during the beginning of the assessment. This will reduce the chance to omit any important information.
Evaluation of the article
LLoyd & Craig (2007) have identified features that are crucial in taking patient history for instance: suitable environment, efficient communication and procedures that are engaged in the history taking process.

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The article is clear on the importance of collecting information in taking patient history. It is beneficial for its step-by-step framework and I could adopt it in my practice. I think that the article gives enough information about different aspects of history taking. The part I like the most is its organization. It emphasizes the need to follow an order during the procedure. They failed to emphasize of the importance of culture during the process. It is a broad article, does not target any particular group in the population. More research articles should be written about this area of health assessment.
The ability to take an accurate history from a patient is an important tool in treatment and diagnosis. LLoyd and Craig (2007) have identified several components that are significant in establishing proper recording of the patient’s history by providing an analysis of the patient’s history taking process. Properly assessing patient is not only help in prioritizing care but also in delivering quality care to patient.

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