A guide to taking a patient’s history

Abstract

This article outlines the process of taking a history from a patient, including preparing the environment, communication skills and the importance of order. The rationale for taking a comprehensive history is also explained.

HIRAID: An evidence-informed emergency nursing assessment framework

“…21 Nursing education literature recommends that a patient's history should comprise of details about the patient's presenting problem and individual health history. 22,23 Various Table 1 Summary of the main sources of evidence informing the HIRAID assessment framework.…”

Taking a patient history: the role of the nurse

“…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.…”

“…Fostering history taking skills Lloyd and Craig (2007) and Douglas et al (2009) give clear and systematic guidelines for taking a comprehensive patient history (Box 3). The importance of effective communication in history taking is evident in both medical and nursing curricula.…”

“…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 andCraig 2007, McKenna et al 2010). History taking was not included in nursing textbooks in the past as it was seen Guidelines on how to write a practice profile as the remit of medical colleagues.…”

Medical Emergencies in Dental Office: An Overview

“…A person's medical record is formed from many various pieces of data that tells the entire story that individual's current and past health. A complete medical history record should include information [9] Diagnosis, Known Allergies, Current Medications, Past and Present Illnesses, Medication History, Current Doctors, Emergency Contact Information -Previous Surgeries, Previous Hospitalizations, Family Medical History, Immunization Records Insurance Information [9].…”