Introduction
Taking a patient’s history is many times crucial for their diagnosis and subsequent treatment. That is why hospitals and treating institutions tend to give much importance to the history of patients. Precisely, because of this importance, it is crucial to have a good patient history-taking process. The medical history of a patient is very important in the determination of the type of treatment and the approach to this treatment. It has special importance for nurses as it allows them to approach the patient and build a solid relationship with them.
Article summary
This article is about this important process of history taking. It outlines the way how a patient’s history should be noted and what relevant steps should be taken in order to have the best results. The article starts with the importance of the preparation of the environment and its crucial role in a successful process. It is the phase when nurses have the most interaction with patients, and they should be careful. It is very important that the environment be free from any distraction, to be accessible, and have all the necessary equipment. Other than this professional aspect, the nurse should be attentive to the patients’ cultural background, and values respect their confidentiality. The final aspect of this phase is that the process should not be interrupted.
Communication is the key to a successful process. The nurse should be able to “gather information in a systematic, systemic and professional manner” (Lloyd and Craig, 2007, pg. 42). In order to achieve these, good communication skills are more than necessary. The nurse needs to build a professional and personal relationship with the patient, both verbal and nonverbal, showing interest in their health history. This is crucial in order to gain total consent from the patient. Consent is important for an appropriate history-taking process. The article then continues by describing the steps during the history-taking process, order and structure, and the types of questions. Finally, the article concludes with the Calgary Cambridge Framework of patients’ medical history recording.
Evaluation of article
This is quite an interesting article for a nurse graduate to read. It attracts attention and interest regarding the importance of a procedure that many nurses do not consider important. In fact, this article makes a clear argumentation of its importance. That is the main thing one can learn from it. Another important aspect of the article is the detailed description of the phases the steps needed to be taken during the patients’ medical history taking. It emphasizes the importance of each step and its linear timing. It is important not to change the lineage of the phases, and that is something many nurses fail to do during their practice. This is also something that all of us practicing could incorporate in our practice in order to achieve better results in our profession. The authors make it easy for each practicing nurse to adopt it in their practice since they format the article like a manual with practical steps to be implemented supported by a rationale for each step. What makes it easier is that the health assessment strategy was clearly explained. Another positive aspect is that it is a strategy that could be applied to a vast number of populations and cultural groups. That is because it has embedded in it the various modifications which should be adopted when a nurse encounters individuals with various cultural and values backgrounds. This is arguably the greatest benefit of this article. Many times during their practice, a nurse is encountered with difficult situations involving patients with different cultural, religious, and values background. These factors make it more difficult to properly extract a medical history from the patient and design and implement a medical intervention or treatment.
Nevertheless, the article fails to give practical examples of how a nurse should react when encountering this type of situation. Another shortcoming of the article relates to the communication phase. The authors explain that it is important, but they do not give any practical advice or example that a nurse can use in order to build confidence with patients through the communication process. These practical examples or demonstrative situations can be very helpful in fastening the reaction of a nurse, especially during an emergency situation.
Conclusion
Of course, no author can comprise in their study all the important aspects of a research question. The same is true for the article just reviewed in this paper. Nevertheless, this is the main reason why more research is needed relating to the issues that this article raises. There is a need for more research relating to both theoretical elaboration and practical implementation. There is also the need for a sort of information campaign to be conducted and address nurses in order to pay more attention to the patients’ medical history-taking process.
References
Lloyd H. & Craig S. (2007) “A guide to taking patient’s history”, Journal of Nursing Standard, vol. 22, Issue 13, pg. 42-48.