Oct 31, 2019 in Medicine

The taking of a patient’s history is one of the most vital aspects of the patient assessment, and nurses need to undertake it on a regular basis. During the procedure, the patients have the opportunity to present an account of their problem, providing essential information to the doctors. Through patient assessment, the nurses continuously expand their roles with the new assessment skill. The assessment of the patients’ history can be performed by most of the assessment nurses, as it is one part of the assessment. It is also likely to be undertaken in conjunction with other patient’s information gathering techniques, to formulate a single assessment process. The process of taking the history of the patients is not new.

Many theorists have examined the health deficits, which rely on the patient's needs during treatment. Other studies have revealed an interaction of the theories, which have sought to develop the existing relationship between the patients and the nurses, through the process of systemic assessment of health. Before taking the history of the patient, the nurses should seek consent from the patient. The consent can be sought through the Code of Professional Conduct or the Good Practice in Consent Implementation Guide (Department of Health, 2001). The code states that the patients can provide information about themselves if they are able to under their own free will.

Summary of the Article

The article outlines the process of taking a history from a patient. It includes the preparation of the environment, communication skills, and significance of the order. Within the article, the rationale for taking the history of the patients is outlined clearly. The initial part of taking a patient's history involves the preparation of the environment. The nurses can encounter patients in different environments within the hospital. As a result, it is essential for the hospitals to ensure that irrespective of the environment, the equipment for the assessment is available. In addition, the patient needs enough time to complete the history-taking process. Lack of enough time could result in the provision of incomplete information. The nurses should be able to gather the information they need from the patient in a systemic manner. In this case, good communication skills are essential. For instance, while taking the history of the patients, the use of technical terms should be minimal when possible. This article provides the reader with a full framework to adopt in taking a comprehensive history of the patients. The history of the patients can be obtained using open and closed questions or through the means of clarification (Lloyd & Craig, 2007).

Evaluation of the Article

The article provides important information essential when conducting patient history assessment. For instance, the authors of the article have provided information on why the environment plays a big role in the success of the history-taking process. For patients, the assessment takes place in different areas of the hospital; all the entry points should have an ample environment for the assessment. Furthermore, communication plays a significant role in achieving a successful assessment of the patient. The article gives a clear overview of the procedural method of communication that could be adopted by the nurses. For example, the procedure outlined involves the use of open or closed questions. After the questions, the patients have ample time to respond. After taking the history, it is essential to summarize the history of the patient for clarification (Lloyd & Craig, 2007).

The article has outlined a procedure for the history-taking sequence. This sequence is very appropriate as it starts with general questions, followed by personal questions. This builds an effective rapport between the patients and the interviewer. The authors emphasize the use of the Calgary Cambridge Observational Guide to include structuring in consultation. This is useful because it ensures a continuous learning process for the nurses through experience. The assessment model could be useful in any hospital, as it is easy to follow. Through the approach, the nurse and the patient achieve a shared understanding of the underlying problem (Lloyd & Craig, 2007).

The authors organized the presentation of the points in an excellent manner, with boxes that summarize the key points discussed in the main document. The summaries make it easier for the reader to quickly grasp the important information. After the evaluation of the article, it is recommendable that a further similar article should be published to improve the volume of knowledge in this area. Furthermore, quantitative research could be beneficial to gather different views from different professionals concerning the importance of history taking processes. It is further essential for the nurses to receive training on competency-based assessment, which will improve the process of history taking in the future (Lloyd & Craig, 2007).

The assessment strategy is beneficial to all the nurses and I would gladly adapt it to my practice. The nurses carrying out the assessments benefit more from the report described in this article. The article could be improved by describing different models and procedures. These are essential in the future to ensure that the nurses have the chance of selecting the best approach that is beneficial to the patients.

Conclusion

From the evaluation, it is clear that the article is providing important information. The information in the article was well organized. The assessment strategy proposed in the article is potentially beneficial for all nurses. The article presents a practical guide relevant to history taking approach using the systems approach. The article outlines all the required key points that are essential in taking a patient history including the preparation of the environment to communication skills and the importance of order. However, while the article provides a rich knowledge of the different means for taking a history, the best skill is through a validated training course, focusing on competency-based assessment of the nurses. This will ensure that the history-taking interview is of high quality and follows the guidelines set in the Code of Professional Conduct.

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