History taking for nurses

history taking is very important component of nursing innervation without it nursing care is not complete.

1. History Taking
NaziaNoreen/Nursing Instructor
SON,LRH

2. Objectives
Be able to:
Understand the importance of the medical history
Identify the relevant processes involved in taking a
medical history
Recognize the importance of structure in a systematic
approach to history taking
Understand the importance of ‘red flags’
Be able to take a systematic, comprehensive history from
a patient

3. WHY
“Without a good history it is an inevitable fact that the
patient’s problem will remain undiagnosed, despite
examination findings and the results of investigations
that follow”
is arguably the most important aspect of patient
assessment, and is increasingly being undertaken by
health professionals other than doctors
(Fishman & Fishman 2005)

4. Why do we take history from the
patient?
80% of diagnoses in general medical clinics are
based on the interview (Epstein et al 2003)
76% correct diagnosis after taking a clinical history
only (Peterson et al 1992)
83 % of doctors made correct diagnosis on the basis
of medical history only (Hampton et al 1975)

5. What is the purpose of the
‘medical interview?’
To identify ‘problems’.
To explore the health/illness of the patient
To plan for the next step

6. History Taking -Assets
Being empathic
Being attentive
Being articulate
Being friendly but business like
Being interested
Environment!
Introduce yourself
Ask permission to take the history
Have you got the correct person!!
Patients Demographics

7. General Principles
Let the patient tell their story
Listen
Develop a rapport, be friendly
Be interested
Use eye contact
Use appropriate language and terms

8. Utilizing a structured interview process:
Calgary-Cambridge Model.
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session

10. Components of the History
The present complaint
The history of the present
complaint
Remaining questions of
abnormal system
Review of systems
Past medical history
Past surgical history
Drug history
Immunizations
Family history
Social history &
habits

11. Set the Agenda
Use open-ended questions initially
Negotiate a list of all issues -avoid detail!
Presenting complaint(s) and other concerns
Specific requests (i.e. medication refills)
Clarify the patient's ideas, concerns expectations
(ICE)
"Why now?"

12. History Taking
Allow the patient time to tell the story in their own
words.
If you don’t understand something imply the
problem is yours!
If you are unsure about the main problem –
“If I could make just one thing better what would
it be?”

13. History Taking
Pitfalls
The patient does not always know what is and what is not
relevant
Hence the importance of a systematic enquiry
The patient has an almost universal tendency to describe
his/her symptoms not directly but in terms of what he/she thinks
they are due to e.g. Neuritis, Rheumatism
What do you mean by?

14. History Taking
Examples of techniques
Open enquiries
e.g. Tell me about your pain?
How did you react to the tragedy?
Closed inquiries
When did your pain begin?

15. History Taking
Examples of techniques
Open enquiries
e.g. Tell me about your pain?
How did you react to the tragedy?
Closed inquiries
When did your pain begin?

16. History Taking
Precision is important, questions such
as:
Q. “Do you ever get breathless?” are
totally useless without qualification

17. Structure
Presenting Complaint
History of Presenting Complaint
Past medical history
Drugs (medications/allergies)
Family history
System enquiry
Social history

18. History Taking
Open questions
Clarification
Reflection -involves putting back to the patient a
symptom or remark
Summary -an expansion on reflection

19. Hist Direct Questioningory
Taking
Sequence of events
How things are currently
Other symptoms
Associated with possible differential diagnosis
In the same system as main presenting symptom
Important negatives
Risk factors

20. Key points
What to ask and how to ask it
Open ended questions are better than closed questions in
establishing framework of the history
Closed questions provide detail and sharpen the account
Keep the history flowing
Minimum of interruptions
Use reflection and summary when appropriate
Use the patient’s own words
Avoid technical terms

21. Secondary History
Expands on the primary history, especially any
associated symptoms.
These questions often bring out information that
supports a certain diagnosis or helps you gauge the
severity of the disorder.

22. Past Medical History
Open questions
What illnesses have you had?
(include psychiatric conditions if
appropriate)

23. Past Medical History
when?
any?
what?
previous
Vaccinations
Screening
Medicals
alcohol
smoking

24. Drug History
Not just prescribed drugs -include over the counter
remedies and alternative medicine
Name each substance, dose and duration
Compliance
Drug allergies & sensitivities

25. Medication and Allergies
Medication
Generic name if possible
Dose
Route of administration
Recent change
Include OTC and homeopathic / herbal
Recreational drugs
Allergies & Sensitivities
When? Diagnosed?
How presented, symptoms

26. History Taking
Family history
Open question -‘tell me about any illness(es) which
run in the family
Ask specifically about immediate family including
parents
Diagnosis and age
Cause of death

27. Social History
Family situation
Relationships incl. Marital status
Occupation
Past and present
Exposure
Community Involvement & Network
Hobbies

28. Social History
Alcohol history
Quantity and type
Place of drinking
Alone or accompanied
Money spent
Purpose

29. Social History
Tobacco
Duration
Type -pipe, cigarettes, cigars
Amount
If stopped when

30. Systematic Inquiry
General
Well being
Appetite
Sleep
Energy
Weight change

31. Systematic Inquiry
Direct questioning
Organise symptoms by system
Explore any positives with open ended questions and
then clarify as per presenting complaint
Use lay terms
Summarise
Anything else?

32. Systematic Inquiry
C.V.S.
Chest pain
Breathlessness
On exertion
Lying flat
Wake up at night
Orthopnoea
Palpitations
Ankle swelling
Exercise Tolerance
Pain in legs when walking

33. Systematic Inquiry
R.S.
Shortness of breath
Chest pain
On inspiration
Cough
Sputum
Blood
Wheeze

34. Systematic Inquiry
GI System
Dental / Gum Problems
Reduced appetite/weight loss
Swallowing
painful
difficult
Indigestion, heartburn
Abdominal pain
Vomiting
Altered bowel habit
Blood loss

35. Systematic Inquiry
Urogenital
Pain on passing urine
Frequency -day, night
Colour of urine
Males:(age), difficulty starting, poor stream,
dribbling, discharge, libido
Females: menarche, menopause, frequency,
regularity, urge or stress, incontinence,
discharge, abnormal bleeding, libido

36. Systematic Inquiry
CNS
Weakness
Disturbance of sensation
Headaches
Visual disturbance
Dizziness, blackouts (clarify these)
Fits
Confusion
Disturbance of speech
Hearing

37. Systematic Inquiry
Locomotor
Joint Pain
Joint Stiffness
Swelling
Mobility
Gait
Falls
Redness and warmth

38. Systematic Inquiry
Endocrine
Heat intolerance (change)
Cold intolerance (change)
Change in sweating
Thirst and Polyuria
Prominence of eyes (change)
Swelling in neck
Energy

39. Systematic Inquiry
The Skin
Rash
Spots
Itching
Ulcers
Lumps/growths

40. Systematic Inquiry
Sleep and rest

41. Summary
Salient features of
Presenting history
Relevant past history
Background
Differential diagnosis

42. Summary
Explanation
Most important from the patients point of view
Communication skills are vital
Speak clearly and audibly
Avoid jargon
Avoid emotive words
Most important information first

43. REFERENCES
Quilliam, S. (2011). "'The Cringe Report': Why patients don't dare ask questions, and what
we can do about that". Journal of Family Planning and Reproductive Health Care. 37 (2):
110–2. doi:10.1136/jfprhc.2011.0060. PMID 21454267.
Mayne, JG; Weksel, W; Sholtz, PN (1968). "Toward automating the medical history". Mayo
Clinic Proceedings. 43 (1): 1–25. PMID 5635452.
Cash-Gibson, Lucinda; Pappas, Yannis; Car, Josip (2012). "Computer-assisted versus oral-
and-written history taking for the management of cardiovascular disease". In Car, Josip
(ed.). Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD009751.
(Retracted, see doi:10.1002/14651858.cd009751.pub2. If this is an intentional citation to a
retracted paper, please replace {{Retracted}} with {{Retracted|intentional=yes}}.)
Tideman, R L; Chen, M Y; Pitts, M K; Ginige, S; Slaney, M; Fairley, C K (2006). "A
randomised controlled trial comparing computer-assisted with face-to-face sexual history
taking in a clinical setting". Sexually Transmitted Infections. 83 (1): 52–6.
doi:10.1136/sti.2006.020776. PMC 2598599. PMID 17098771.