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Abstract
History taking is a key component of patient assessment, enabling the delivery of high-quality care. Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients' problems. Care priorities can be identified and the most appropriate interventions commenced to optimise patient outcomes.
Keywords
Assessment, care planning, communication, history taking, nursing skills
Aims and intended learning outcomes
This article explores history taking as a key component of patient assessment. The goals of history taking are explored, with specific reference to medical and biographical history taking, to promote and enhance knowledge of the complex skills involved. This article does not detail how to take a history as this is explained elsewhere (Lloyd and Craig 2007). Rather, the focus is on how to think about and foster the skills of history taking to understand the patient's circumstances and experience of a particular healthcare problem or need. After reading this article and completing the time out activities you should be able to:
*Explain the importance of history taking in the context of patient assessment.
*Outline guidelines for taking a patient history.
*Discuss how biographical details can complement medical history taking.
*Explore how key history taking skills and processes can be used to optimum effect when planning care for different patient groups.
*Consider how history taking skills might be fostered or improved in the future.
Introduction
Although nurses acknowledge that patient assessment is the cornerstone of nursing care, they are perhaps less comfortable with the idea of formally taking a patient history (Lloyd and Craig 2007, McKenna et al 2010). History taking was not included in nursing textbooks in the past as it was seen as the remit of medical colleagues. However, from the 1970s onwards, the nursing process of assessment, planning, implementation and evaluation was embedded; history taking (including concomitant communication skills) became an integral, albeit informal part of nursing assessment. The focus of history taking involves not only identifying signs and symptoms of illness, but also the individual's experience of illness. Taking a patient history is increasingly being undertaken by nurses as their roles and responsibilities expand. This is particularly the case for nurses working in advanced practice roles in a medical setting.
The person-centred approach to care,...