This article by Hilary Lloyd and Stephen Craig discusses in-depth the process related to recording the medical history of a patient which includes preparing the environment in which the history will be taken down, the skills required to communicate effectively with the patient, and the need for order related to how the history is arranged. In addition, Lloyd and Craig examine “the rationale for taking a comprehensive history” of the patient via a systemic enquiry (2007, p. 42).
This article is composed of seven distinct sections–1), preparing the environment for the recording of a patient’s medical history; 2), communicating with the patient in a responsible, caring, and orderly manner; obtaining patient consent or confidentiality prior to recording his/her medical history; 4), the history-taking process; 5), the Calgary Cambridge framework as a “model of consultation” (Lloyd & Craig, 2007, p. 44); 6), taking the patient’s history; and 7), a concise conclusion to the discussion.
The first section explores the overall importance of the environment when taking a patient’s medical history. For many nurses, the environment may be an emergency ward, a general ward, a specific department, a primary care center, or the home of the patient. In any case, the environment must be convenient, safe, and free of all distractions for both the interviewer and the patient. One of the most essential elements is to make certain that there is plenty of time available to properly complete the history; otherwise, the information may not be wholly accurate which could negatively affect the care and outcome of the patient’s primary medical complaint (Lloyd & Craig, 2007, p. 42).
The second section discusses the importance of communication between the nurse and/or interviewer and the patient. In order for the history to be comprehensive, the nurse/interviewer must be able to collect all of the information and data in a professional manner and know how to be sensitive to the patient’s needs while also practicing good communication skills. Also, the nurse/interviewer must develop a close relationship with the patient by being receptive and cordial and by using non-verbal skills, such as appropriate body language (Lloyd & Craig, 2007, p. 42).
The third section notes the importance of obtaining informed consent from the patient. The best way to accomplish this according to Lloyd and Craig is to consult two appropriate sources–the Nursing and Midwifery Council’s Code of Professional Conduct and the United States Department of Health’s “Good Practice in Consent Implementation Guide” which mandates that a patient must be able to provide consent voluntarily while also understanding the reasons for the questions in advance (Lloyd & Craig, 2007, p. 43).
Following informed consent from the patient, the nurse/interviewer then proceeds to the history-taking process itself which begins (after some introductions) by asking how the patient wishes to be addressed during the interview, such as by a first or last name. Then after obtaining some basic demographic details like the patient’s age and occupation, the nurse/interviewer should follow a specific sequence of events that includes 1), the patient’s former medical history; 2), the present condition of the patient’s mental health; 3), a brief overview of the patient’s medication history; 4), histories related
to the patient’s immediate family, social and sexual relationships, and past and present jobs related to the initial medical disorder; 5), a systemic enquiry that usually involves questions about other body systems that may or may not be related to the initial medical disorder; extra information and data from the patient’s wife/husband and/or children; and 7), a summary or general description of all the information and data gathered from the patient (Lloyd & Craig, 2007, p. 43).
In addition, the nurse/interviewer should understand the details of the Calgary Cambridge Observation Guide before proceeding to take the medical history of the patient. Five of the most important aspects outlined in this guidebook includes making sure that the information is correct; aiding the patient in recalling information via personal reflection; encouraging the patient to interact with the interviewer via a personal perspective; working with the patient to help him/her to understand how the end results of the history-taking process will affect future medical decisions; and lastly, ending the consultation with an explanation related to a medical plan or course of action that is “acceptable to the patient’s needs and expectations” (Lloyd & Craig, 2007, p. 44).
Overall, this article is well-designed and written and should be completely understandable to all that read it. One of the most outstanding aspects is the inclusion of a number of boxes that have been designed as quick reference guides for the reader. For example, Box 1 on page 43 provides examples of verbal and non-verbal communication skills that will definitely help the nurse and/or interviewer to create an excellent patient history report. Box 3 on page 44 offers examples of interviewing techniques that the nurse/interviewer must avoid, such as asking questions about how and why a patient is experiencing a specific disorder or illness; using technical jargon that the patient will not understand; offering stereotypical responses to patient questions; providing false assurances to the patient in regards to the prognosis or diagnosis of their particular disorder or illness; and asking the patient specific questions that the nurse/interviewer hopes will lead to the answers he/she wants to hear.
Box 5 refers to what is known as the CAGE System in relation to asking a patient questions about problems with alcohol. This is followed by a quick guide for the nurse/interviewer on the equivalent units of alcohol as found in beer, wine, and hard liquor or spirits. Essentially, these boxes help to support the text which is presented by Lloyd and Craig in a rather straightforward manner without the inclusion of technical terms and jargon. Perhaps the best part of this article is the extensive reference list which includes medical books, medical journals like JAMA, and a wide variety of other sources that the nurse/interviewer will find especially useful as reading/studying material prior to taking the medical history of a patient.
Essentially, this article serves as an excellent sort of beginner’s guide on how to successfully take the medical history of a patient. Lloyd and Craig admit this in their conclusion by declaring that this article is a realistic reference source to taking a patient’s medical history via a systematic approach that has been utilized by other health care professionals for many years. However, despite this fact, Lloyd and Craig point out that the best way for a nurse to achieve the necessary skills and abilities related to taking the medical history of a patient is to participate in a professional training course or seminar that focuses on competency (2007, p. 48). Nonetheless, Lloyd and Craig’s article is an excellent primer for nurses and other health care professionals who may find it part of their jobs at some point in their careers to conduct an extensive and perhaps life-saving patient history.
Lloyd, H., & Craig, S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13), 42-48.