Guide for Patients History Taking (Essay Sample)

Guide for Patients’ History Taking
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Introduction
Nursing as a profession contains challenging tasks that require a lot of concentration or reminders in order for an individual to have information at hand. Following the myriad challenges that nurses encounter in the fields of duty, the article author, Lloyd H, Craig S (2007) who is a principle lecturer in nursing practice, development and research. City Hospital Sunderland NHS Foundation Trust, Sunderland, and Stephen who is also a senior lecturer in nursing, Northumbria University Newcastle open type.
The article was availed due to the necessity and uncertainty in the nursing staff due to forgetfulness and the monotony (being rubric to) lack of exposure to other nursing duties. In most cases, nurses conduct the diagnosis and patients to determine the diseases that are affecting the patients, as well as determine the level of infection, in patients. Evidently, nurses administer medication to patients and are accountable for guaranteeing that the welfare of patients is prioritized at all times (Lloyd & Craig, 2007, p. 46).
Therefore, nurses play a central role in ensuring that patients receive appropriate and quality treatment; as they help doctors in providing healthcare services to the public. The provision of effective health care to the patients largely relies on the quality, validity and soundness of information, which is corrected from patients by nurses to facilitate the process of treatment and diagnosis of diseases.
This brief write up will summarize the steps and strategies of collecting information from patients to aid the treatment process. Further, the paper will evaluate evidence of the steps and strategies that are employed, by nurses to collect information from patients and end with a concise but summative conclusion (Lloyd & Craig, 2007, p. 44).
Summary
The history of a patient is central in the structure and approach of intervention by doctors; thus the most essential aspect of patient assessment. This procedure of history taking grants a patient an opportunity to present the account of their disease or problem and nurses are mostly involved in this procedure.
The process of collecting information from a patient is crucial in a hospital setting; as the medical personnel depend, on information from patient to design the treatment process; and circumstances that they encounter patients to ensure that they reap the entire vital information from a patient (Lloyd & Craig, 2007, p. 59). The working environment should be accessible, convenient and safe for both the patient and nurse. Further, the nurse should observe professionalism and refrain from disrespecting a patient or ignore their belief systems (Lloyd & Craig, 2007, p. 64).
Effective communication is essential in taking the history of a patient and nurses should be equipped with competent communication skills, which enable them reap plenty of vital information from patients concerning their ailment. Therefore, communication is central in compiling a comprehensive patient history, and people with competent communication skills can manage to prepare a sensitive and systematic history while adhering to professional standards (Lloyd & Craig, 2007, p. 104). Essentially, nurses should record the history of patient using the language and understanding of the patients, but not attempt to translate and employ jargons in the history of patients.
Closed ended questions should only be applied when seeking specific and detailed information, which helps a nurse narrow down the symptoms of diseases and the period that the patient has suffered (Lloyd & Craig, 2007, p. 106).
Further, the article describes the process of taking the patients’ history. This process begins with introduction where the nurse states his name, gains consent of the patient and states his purpose (Lloyd & Craig, 2007). Further, the structure and order of the history should follow a systematic and logical approach, which is approved by the nursing and medical texts.
Patients are asked open questions first, and the open questions are followed by closed question, which are then followed by clarification of information gathered through restating the information collected to the patient for confirmation. A nurse should be keen to ask the patient for additional information that the patient might be willing to share (Lloyd & Craig, 2007, p. 85).
The Calgary Cambridge developed a frame work of consultation called the Calgary Cambridge Observation Guide, which structure the entire consultation between a nurse and a patient. According to this model, five stages can be utilized to summarize a patient’s history. The initial stage is planning and explanation, which is closely followed by aiding accurate understanding and recall (Lloyd & Craig, 2007, p. 67).
Further, the nurse should achieve an understanding that is shared by both the nurse a patient. The next stage is planning a decision making process, which should be shared, as well, and the last stage entails closing the consultation. Following the model proposed by Douglas et al (2005), history taking follows the following pattern (Lloyd & Craig, 2007, p. 72).
This stage is followed by enquiring the past medical history of the patient, which gives the nurse essential background information about the treatment and medication of the patient, in the past. Further, the mental healthcare of the patient is evaluated and recorded appropriately (Lloyd & Craig, 2007, p. 55).
Notably, the medication history should follow the mental health report to determine the category of drugs that the patient had been using if any, as well as the quantities taken (Lloyd & Craig, 2007). The family history of the patient and the social history follow medication history ...