Topic > The importance of taking an accurate medical history

Introduction“A guide to taking a patient history” is an article that appeared in volume 22, number 13 of the Nursing Standard Journal in December 2007, written by H. LLoyd and S. Craig. The article talks about the steps and strategies to follow when taking the patient's medical history. It is important to acquire good techniques to evaluate a patient starting from the environment, communication skills and a systematic approach. You need to be able to collect accurate data to facilitate the process. Summary The article begins by emphasizing the environment when taking the patient's medical history. The environment must be safe for both the patient and the nurse. The environment should be quiet and, ideally, there should be no interruptions (LLoyd & Craig, 2007). For proper collection of the patient's medical history, the environment should be prepared well in advance. An important issue identified in the article is communication as a basis in managing the history-taking process. For adequate communication to occur between the patient and the nurse, there must be sufficient interaction between the two. Both verbal and non-verbal skills are needed. Questions should not be judgmental. Open-ended questions provide more general information about the patient. The Calgary Cambridge framework is one of the methods used. The nurse must treat the patient with respect and dignity and do everything possible to keep the patient confidential. Furthermore, the patient needs time to provide a complete medical history. It is best to avoid technical terms that the patient may not be able to understand. It is important for the nurse to express himself clearly to avoid confusion. The patient's consent is required before starting the process. It is also important to ask the patient about health beliefs and practices. Once the general structure of the medical history is established, you can begin to ask about presenting disorders, past medical history, mental health followed by medication history. It is important to inquire about the over-the-counter medications and herbal remedies the patient is currently taking. Family history is also an excellent tool for collecting the patient's medical history. The patient's social history should also be included in the sexual history and occupational activities. The nurse should gather information about other body systems that are not covered during the initiation of the assessment. This will reduce the possibility of omitting important information. Evaluation of the article Lloyd and Craig (2007) identified crucial characteristics in patient history taking, for example: suitable environment, efficient communication and procedures involved in the history taking process..