Guide to Taking Patient's History - Admission/Application Essay Example

Download file to see previous pages Taking patient history has been said to create a good relationship between the patient and the practitioner. The article redefines the patient’s health assessment, apart from history taking; information is gathered through single assessment and nursing assessment. The authors lay emphasis on the environment, communication and patients consent. The process of history taking has been greatly emphasized to ensure efficiency, a laid structure involves; preparation of environment, introduction of the practitioner, purpose of the history taking process and getting to know the patient. The article gives an overview of patients symptoms, how to analyze this symptoms to make a clear conclusion on the patient’s sickness. A guide to interviewing a patient has been well explained, questions to avoid when interviewing a patient have been outlined. For example, asking leading questions, exaggerated approvals and use of probing questions. The article summarizes history taking process by starting with the present problem, past medical history, mental health, medication history, family history, social history and systematic enquiry. The article introduces appropriate skills required in history taking; this can be acquired through a training course that has competitive assessments. Summary An appropriate environment is important when taking history from a patient, an environment is different for nurses, and it could be an accident scene, hospital wards, heath care facilities and even homes of patients. Therefore, prior preparation is essential to ensure effectiveness. The environment should be quiet and accommodating for the two parties. Respect should be highly held for a patient, a nurse should ensure that the values and beliefs of the patient are not interfered with during the history taking process. To ensure a clear environment, a nurse should avoid judging the patient. The nurse should keenly observe confidentiality, as well as ensure adequate time during the process. Inadequate time can lead to half-baked information. During history taking, good communication is an important tool. According to Lloyd & Craig, a nurse should gather information in an orderly and systematic manner. (2007, p. 42.).A nurse should make a self-introduction, and then allow the patients to give their own medical history. During this time, a nurse should not be in a hurry to avoid intimidating a patient. A rapport should be established with the patient by being friendly. Communication skills, should be used professionally, for instance, a nurse should put up a good posture, an alert eye contact and facial gestures that show interest. An appropriate language should be adhered to, instead of the medical terms the nurse should use the patient words. The questions should be in asked in an order, a nurse should start with open-ended questions followed by closed questions. After questioning, a nurse should seek clarification from the patient, through asking the question again. At the end of the interview, a patient should be given a chance to add any information that has not been considered. Evaluation The article appreciates the fact that, nurses are also undertaking history taking as part of their duties; with this concern, a patient assessment is essential for all the health practitioners. Other theorists have discussed the process of history taking widely, they emphasize on client interaction while others rely on interaction theories. The article ...Download file to see next pagesRead More