UWE Bristol
History taking
Anna Neary
History taking
Introduction
It is essential to complete this learning activity after completing the
Consultation models and skills activity and prior to any physical
assessment activities within Enhanced clinical assessment and
reasoning unit.
This learning activity looks at the essential components for effective
History taking when assessing patients. The activity also looks at the
role of environment in taking an effective history, exploring tools to
aid the process and addressing the legal aspects of history taking
and documentation.
In this activity, you will:
1. Review the sequence of a history taking interview.
2. Explore the importance of the environment when taking a
history.
3. Explore the history taking format and tools that can be used
to aid this process
4. Address the format of documentation.
5. Be introduced to the legal aspects of history taking and
documentation.
History taking
Taking a history
Taking a history from a patient is the start of an important process for
the patient and the health care professional. It is a conversation with
a purpose and as a health care professional you will use many
interpersonal skills to make sure you establish all relevant
information in order to improve the health of your patient.
Thus the conversation has three aims:
1. To provide a trusting and supportive relationship
2. To gather information
3. To give information
(Hogan-Quigley et al 2012)
History taking
Sequence of interview
The sequence of the interview should be as follows:
•Greeting, establish rapport
•Invite the patient’s story
•Establish the agenda for interview
•Clarify story – generate and test diagnostic hypotheses
•Create shared understanding of problem
•Negotiate a plan and follow-up
•Close the interview
(Hogan-Quigley et al 2012)
Examples of history taking processes in clinical areas include:
•Admission of patient
•Pre-op assessment
•Triage assessment
History taking
History taking setting
It is important to make the patient feel comfortable whilst taking their
history.
Factors to consider include:
Comfort for all involved
Removal of physical barriers
Good lighting
Privacy
Relative quiet
Unobtrusive access to clock
(Douglas et al 2009)
History taking
Your approach to history taking
History taking is one of the most important skills a health care
professional has, without it assessment of health needs becomes
very difficult.
You want your patient to tell you potentially very personal honest
facts about their health, this can only be achieved if you ask
questions in a manner that is not judgmental or assuming.
Patients are often fearful about their health and your role is to
provide a strong nurse-patient relationship to reduce fears and
feelings of isolation.
History taking information is subjective data i.e. what the patient tells
you.
History taking
Preparing for the interview
As with all things it is important to prepare for taking a patients
history, below is a list of the key areas you should cover before
commencing your interview with the patient:
Time for self reflection – what values, assumptions, biases do you
bring?
Review the notes
Set interview goals
Think about your behavior and appearance
Set the environment
Take notes
Timings
History taking
Structure of the history
It is important to create a structured plan to history taking. This will
ensure that details are not overlooked.
Areas to consider are:
•
•
•
•
•
•
•
Reason for seeking health care (Presenting complaint)
History of presenting complaint (patient’s account of presenting
complaint)
Systematic review of body systems.
Drugs and allergies (including over the counter medication)
Past history (surgeries/medical diagnoses)
Family history (genetics, medical/surgical)
Social history (environment, relationships)
(Rushforth 2009)
History taking
Presenting complaint
This outlines the reason why the patient
is seeking health care and should
consist of two to three words. For
example:
•
Central chest pain
•
Abdominal pain
•
Pain in ankle
•
Shortness of breath
History of presenting
complaint (HPC)
Mnemonics help shape stories; these
will help you not to omit details in the
history taking and documentation
process. OLDCART is a mnemonic that
can be used to help take the history of
presenting complaint (Douglas et al
2009).
O
• Onset (When did the pain begin?)
L
• Location (Where is the pain, does it go anywhere
else?)
D
• Duration (How long does the pain last? Is it constant
or intermittent?)
C
• Characteristics (Is the pain sharp, shooting, burning,
electrical? Is it a dull, aching or grinding pain? Does
the pain feel like cramping or squeezing?)
A
• Aggravating factors (Do activities like moving,
walking, sitting, turning or touching worsen the
pain?)
R
• Relieving factors (What medical and non medical
interventions relieve the pain?)
T
• Treatment (What treatment has the patient tried
e.g. heat, elevation, simple pain relief, rest?)
History taking
THREAD
THREAD is a mnemonic used for past medical history, it reminds
you to enquire about significant illnesses:
•T – TB
•H – Hypertension
•R - Rheumatic Fever
•E – Epilepsy
•A – Asthma
•D – Diabetes
(Douglas et al 2009)
Drug and Allergies
Prescribed drugs include the name, dose and route and frequency of
use. You must also ask about over the counter medicines including
herbal remedies.
History taking
Systematic review of systems
Understanding the review of systems can be a difficult
concept to get right. You will be asking a series of
questions going from head to toe, you are trying to find
clues in the form of symptoms to help you come to a
diagnosis.
Here are the questions you would need to ask for the
review of the main systems:
Respiratory system
– Do you ever get short of breath?
– How many pillows do you sleep with at
night?
– How far can you walk before you get short
of breath?
– Do you have a cough?
– Do you cough up any sputum?
(Hogan-Quigley et al 2012)
Cardio-Vascular System
•
Do you ever get any chest pain?
•
Do you ever get any palpitations?
•
Do you ever get short of breath?
•
Do you ever have swollen ankles?
Gastro-intestinal system
•
How regular do you have your bowels open?
•
What do your stools look like?
•
Do you have any vomiting or diahorrea?
•
How is your appetite?
•
Have you had recent weight lose?
(Hogan-Quigley et al 2012)
History taking
Family History
It is important to establish whether there are any genetically
transmitted diseases within families, these include, coronary artery
disease, hypertension, elevated cholesterol disease, stroke,
diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or
lung disease, headache, seizure disorder, mental illness, suicide,
substance abuse and allergies
Social history
It is important to also establish the context in which the patients live
as such factors can have an impact on an individual’s health. Such
as occupation, drug (illicit) and alcohol consumption, hobbies, family
situation and domestic violence.
Documentation
Documentation is a piece of writing that accuracy reflects patient
care. It ensures safety for the patient and a record of events. It is
important that these records are performed soon after the
patient/nurse assessment to ensure accuracy. See appendices for a
template to support your documentation of a patient’s history.
History taking
Summary
You have now completed this activity. Here is a summary of the main
points:
•
You have looked at the sequence of history taking in the context
of the medical model.
•
You have learnt about the importance the environment when
taking a history
•
You have looked at mnemonics to aid the history taking process
i.e. OLDCART and THREAD
•
You have looked at the format in which to document your
history taking.
•
Your guided learning will lead you through the legal aspects of
documentation
History taking
References


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•
Dimond B (2008) 5rd Ed Legal Aspects of Nursing London :
Prentice Hall
NMC (2010) Guidelines for records and record keeping. NMC :
London
Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s
Clinical Examination. Churchill Livingstone
Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012) Bates’
Nursing Guide to Physical Examination and History Taking. First
Edition. Lippincott, Williams and Wilkins.
Rushforth, H (2009) Assessment made incredibly easy. First UK
Edition. Lippincott, Williams and Wilkins
History taking
Guided Learning (three hours)
1.
Take a history from five patients using the OLDCART
mnemonic, for history of presenting complaint, THREAD for
past medical history and use the template below to document
your findings.
2.
Look back at the notes you made previously in this activity to
guide your approach and questions.
3.
Read the PDF documents Record Keeping Guidance and NHS
Information Governance and summarize the guidelines for good
documentation. Discuss your findings with your supervisor.