Article Review
Introduction
This article review has focused on the article: “A guide to taking a patient’s history”. This article was authored by Hilary Lloyd and Stephen Craig and published in the Journal of Nursing Standard in 2007. The article describes the procedures used in recording the account of the patient’s problem. The article recognizes the importance of having well defined procedures for recording patient history in ensuring delivery of quality care. It focuses on issues such as; effective communication with patient, providing appropriate environment for the patients and organization of the entire process. This article provides a useful framework that can be used to enhance the patient’s history taking process.
Summary of the Article
According to Lloyd and Craig (2007), recording the health history of a patient is one of the most important components of the patient assessment process. This procedure provides the patient with an opportunity to give his description of the problem and his experiences. This procedure is mainly implemented by nurses and it is used to obtain important information about the patient’s condition. This article was written with the main objective of providing a comprehensive framework that will enhance the process of taking the history of the patient. In this framework, Lloyd and Craig (2007) have identified essential issues that are important in ensuring effective recording of the patient’s history. One of these issues is establishment an appropriate environment for the patient.
Lloyd and Craig (2007) have noted that effective history taking is dependent on the relationship between the patient and the nurses. The environment is which the patient and the nurse interact is crucial in determining level of interaction between the two parties. Effective history taking is likely to thrive in an environment where the patient and the nurse can interact freely and constructively. Thus, Lloyd and Craig (2007) framework considers preparation an appropriate environment for the patient as the first step towards effective history taking.
It has been noted in the article that patients and nurses can interact in different environment. These environments may include; emergency rooms, accident scenes, patient wards or healthcare center. One way of preparing this environment is ensuring that appropriate equipments are available. It is essential to ensure that when nurses and patients interact, the nurse will be in a position to get the relevant information from the patient. The environment should also be safe for both the nurse and the patient. If the nurse encounters a patient at a scene of an accident, the priority should be on ensuring safety of the patient. Incase, the setting is in a hospital the environment should be secure and private.
Another important issue identified in Lloyd and Craig (2007) framework for guiding the process history taking is communication. Communication is the process through which information is conveyed from one person to another. In order for effective interaction to take place between the patient and the nurse, there must be effective communication between the two. This implies that nurse should have excellent communication skills in order to enhance the process of history taking. Lloyd and Craig (2007) recommend that in order to promote effective communication, the nurse should begin by introducing him or her self to the patient. This will create a personalized relationship between the patient and the nurse thus earning the patient trust.
The nurse should also accord to patient an opportunity to tell his or her description of the problem first and then proceed to ask question. Questions will assist the nurse to get deeper insight on the patient’s problem. In order to retrieve useful information, the nurse should ask open ended and closed ended questions and offer general leads to the patient. Technical terms should be avoided so as not to confuse the patient. The nurse should also clarify information to avoid misunderstanding the patients’ communication.
Lloyd and Craig (2007) framework has also emphasized on the need to obtained consent from the patient before embarking on the process of taking the patient’s history. This should involve informing the patient what they are agreeing to and obtaining ensuring that the consent is willingly given by the patient. This article has also identified a number of areas that the nurses should focus on when record the patients description. These areas include; introduction; taking complaints and recording past medical history including mental health, physical health, family history. Other information that the nurse should focus on include; history of social relations; sexual history and occupational activities.
Article Evaluation
In this article, authors have identified essential elements that can be used to develop an effective patent’s history taking process. These elements include; appropriate environment, effective communication and procedures involved in the history taking process. The authors have effectively described the importance of creating appropriate environment and what this environment should entail. The authors have also explained the importance of communication and address some of the issues that nurses should focus on in order to enhance communication between them and the patients.
However, the author has not discussed the implications of culture to the communication process between the nurse and the patient. This is usually an area of concern in health care and culture can hinder effective communication between the patient and the nurse. The authors have also identified important areas that nurses should focus on when recording the patient’s account and the order with which this information should be collected. The authors have provided explanation of some of the effective ways in which information concerning these area can be obtained from the patient.
This article interests me because it provides useful information concerning the process of taking the history of the patient. Recording the patient description of the problem is an essential step towards delivery of quality care and therefore this information is quite useful to any healthcare professional. This framework provides useful information to nurses, doctors and any other health specialist that is involved in the process of conducting patient assessment. This article has provided an overview of the patient’s history taking process and has described some of the most essential elements that are involved in this process. This overview has identified a number of essential processes in the history taking process. Future research articles should focus on providing elaborate description of how the individual elements of the history taking process can be enhanced. Future articles should also focus on discussing the implication of the “NMC code of professional Conduct” to the history taking process as this has not been adequately addressed in the article.
Reference
Lloyd H. & Craig S. (2007). “A Guide to Taking a Patient’s History”. Journal of Nursing Standard. 22 (13): 42-48
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