A Guide to Taking Patient History - Book Report/Review Example

A Guide to Taking Patient History Introduction The field of nursing research has greatly boomed in the past years, leading to an explosion of the materials available for nurses around the globe. However, a major issue with these literatures and studies is the fact that not all of them can be considered as truly credible. This is where peer-reviews, including article critiques, come in. Article critiques involve the critical appraisal and evaluation of a published work detailing on information regarding a certain phenomenon[Nan05]. Critiques are useful in establishing the worth of a published study or work, as well as in determining what a study may lack or need in order to be really usable in its field of inquiry. In relation, this paper will then attempt to carry out a critique on an article published in the field of nursing assessment. The said article by Lloyd and Craig (2007) focused on the process of assessment, specifically history-taking from a patient. The article discussed the needed steps for effective history-taking, including organizing the appropriate environment, establishing the needed communication skills, and the significant role played by order. This specific literature was chosen because of the significance of the very first step in the nursing process, which is assessment. Indeed, without proper assessment, appropriate interventions cannot be determined, thereby decreasing the patient’s chances for recovery. Also, Brooker and Nicol (2007) noted that assessment is vital in determining the needs of the patient, and inevitably in planning the required interventions. Thus, in critiquing the aforementioned article, this paper will first present a summary of the article, and afterwards, an evaluation and critique will also be discussed. Summary of Article As mentioned earlier, this article critique will focus on the article by Lloyd and Craig (2007), published in the 22nd volume of the Nursing Standard. The said article, entitled “A guide to taking a patient’s history”, focused on the process involved in the acquisition of the patient’s health history, considering several necessary factors such the environment, the nurse’s communication skills, and the order of events in the history-taking. The article began with an introduction on the importance of history-taking as part of nursing assessment. The authors mentioned the expanding roles of nurses, especially when it comes to assessment; therefore, nurses need to know the proper way of taking a patient’s history. The body of the paper was then divided into six main parts, each discussing a significant aspect of the history-taking process. The first section of the body explored the concept of the preparation of the environment as the first part of the process of history-taking. According to the authors, preparing the environment is supported by the idea of respect, wherein providing an appropriate and conducive environment that meets the need of the patient shows that the nurse respects the patient. After environment, Lloyd and Craig (2007) then discussed the importance of communication skills, especially in history-taking. Under this concept, the authors emphasized the vital role of establishing rapport, as well as the need for interpreting both verbal and non-verbal cues. The authors also noted that communication should be made as simple as possible, and that jargons and medical terms should be avoided. After communication, the authors then discussed the idea of informed consent before history-taking. Under this concept, the authors provided a discussion of the legal bases for consent-taking, as well as the consideration of the patient’s mental capability in giving the consent. After exploring informed consent, the authors went to the actual discussion of the history-taking process itself. Under this section, Lloyd and Craig (2007) discussed the proper order of interacting with the patient, specifically in history-taking. After preparing the environment, establishing rapport, and taking the consent, demographic details should be taken first, followed by the patient’s chief complaint, medical history, mental health history, medications taken, background on familial or genetic diseases, social history, the patient’s sexual activities, occupation, and others. After presenting the history-taking process, the authors then discussed a useful framework for history-taking: the Calgary Cambridge Framework. The said framework serves as a useful tool in structuring a consultation, by utilizing five stages to summarize the taking of patient history. Afterwards, the authors then gave a more comprehensive clarification of the process involved in history-taking, by individually discussing which information should be gathered, what to ask to elicit the proper response, and how to interpret the information given by the patient. Each component of the patient’s health history mentioned in the previous paragraph was clearly defined and then expounded. After this section, the authors then concluded the article by summarizing what they have presented and reiterating the importance of quality history-taking. With this, the following section of this paper will then explore the evaluation and critique of the article by Lloyd and Craig (2007). Evaluation and Critique In looking at the article, it can be seen that a positive point made by authors is that their introduction section in the article was able to provide a clear thesis on what the paper will discuss, as well as why it would be discussing the said topic. A strong point of the paper’s introduction is that the authors were able to fully establish a compelling argument on the significance of the article, as well as the significance of the history-taking process itself. Also, in terms of the credibility of the authors, Metcalfe (2003) noted that Lloyd and Craig were able to establish their expertise in the field of nursing by providing a brief discussion of their credentials and qualifications. In addition, the body of the article also had some form of organization, especially since the subheading helped in telling the reader what part will be discussed next. However, an issue with the paper’s organization can be seen in the section of “The history-taking process” which provided a brief background of the main topic discussed, but which was separated from the actual “meat” of the article, the “Taking the history” section. Indeed, by inserting the “Calgary Cambridge Framework” between the said two sections, the flow of the paper was interrupted. In fact, the authors could have just omitted the portion discussing the “taking the history” and instead inserted it into the earlier section of “The history-taking process”. This would have made the flow of the ideas more continuous, and it would have made the paper more organized. Moreover, the section on the Calgary Cambridge framework could have simply been omitted or simply used as a footnote since the authors failed to related the ideas discussed in this portion of the paper to the main content of the paper’s body. Nevertheless, despite this issue on the paper’s organization, the authors were able to clearly explain necessary health strategies. Their arguments were also convincing, especially since they used adequate evidences to support their arguments. The guide for establishing structure of the interview is also very much organized, and will greatly help nurses and health practitioners in gathering the necessary date from the patient. However, an issue with some of the sources used by the authors is that they were rather old, some as old as 1981, although the old sources constituted only a small portion of the references list. Most of the sources also came from books, as well as sites of the government of United Kingdom and websites of other organizations. Although these sources are somehow credible on their own, they were not subjected to adequate peer-review and critique, thereby casting some shadow of a doubt on the sources’ integrity or reliability. To make matters worse, the authors did not really consider the possible counter-arguments for the evidences they provided. For example, they cited Douglas, Nicol, and Robertson (2005) as their primary evidence for establishing their order for interviewing or history-taking, but a later work by the same authors [Joh09] changed the original order to include other history aspects. Another weakness of the paper is the fact that some of the ideas presented were too brief, and some areas that needed a more comprehensive exploration were not fully addressed. It was as if the authors tried to fit in too much of the information into such a small amount of space. Indeed, in terms of space, the authors may have wasted a bit too much of space by including numerous text boxes that needlessly repeated some of the information that were already presented in the body of the paper. Conclusion Indeed, this article by Lloyd and Craig (2007) presented a lot of shortcomings in its structure, evidences, argumentation and others. Still, despite the shortcomings of the said article, it was able to provide a useful source of information regarding the process of history taking. Indeed, this paper can be very much beneficial for students, novice, and advanced nurses who need much guidance in their practice. However, more competent and expert nurses may not be able to fully appreciate the content and structure of the article. Nonetheless, the clarity of some of the discussions and the simplicity of the language used make this article a literature worth reading and using. References Brooker, C., & Nicol, M. (2007). Nursing adults: the practice of caring. New York: Mosby. Burns, N., & Grove, S. K. (2005). The practice of nursing research: conduct, critique, and utilization. Publisher: St. Louis, Mo.: Elsevier/Saunders. Douglas, G., Nicol, F., & Robertson, C. (2005). Macleod's Clinical Examination. New York: Churchill Livingstone. Douglas, G., Nicol, F., & Robertson, C. (2009). Macleod's clinical examination. New York: Churchill Livingstone/Elsevier. Lloyd, H., & Craig, S. (2007). A guide to taking a patient's history. Nursing Standard, 22 (13), 42-48. Metcalfe, M. (2003). 11 Ways to Critique an Article. Retrieved July 20, 2011, from University Of South Australia: http://www.unisa.edu.au/irg/documents/critiquing_articles.pdf Read More