Comprehensive Health History Taking

Comprehensive Health History Taking

In any medical setup, conducting patient’s interview and recording of necessary information plays a fundamental role in the practitioner’s examination process. This process is very crucial as it may affect the perception and the attitude of a patient. This paper therefore, discusses some of the effective interviewing techniques for collecting patients’ health information.

Normally different patients visit health facilities with different ailments. The first step is to establish a positive relationship with the patient. This is established by welcoming and portraying respect. The tone of voice of the nurse should be calm and warm. This allows the patient to feel relaxed to provide or explain the ailment (Brummel-Smith & Halperin, 2013). The patient is the chief complainant and describes the significant signs or symptoms of illness. During this interview, information from the patient is sourced including general health and lifestyle, changes in health since the last visits to the hospital and medical and health history. Other interviewing techniques or skills that one must posses include effective listening. It is prudent for the nurse to be very attentive in listening, thinking about a certain aspect and when responding (Both, et al 2009). This will ensure that important information is noted hence aiding in proper medication. It is also important to be sensitive about nonverbal cues and body language as they communicate a lot. Understanding these cues enhance the interview. It is also essential for an individual to have broad knowledge base that will enable an individual to ask relevant questions to stimulate more information and for clarification.

Other follows the eight steps of interviewing. It is important to carry out a research before the interview by reviewing the records of the patients and ensure that all the test and lab results are present on the chart. This ensures that important and relevant information is available. The interview should be planned. Planning ensures that enough preparation is done making it organized and to adhere to the stipulated rules. Planning also allows an individual to have that confidence on how the interview will be done. The patient should be made to feel relaxed and at ease. This can be achieved through eye contact and use of icebreakers. The advantage of this is that it allows the patient to give information better without feeling stressed and depressed. The patient should then be requested for an interview. The importance of the interview needs to be emphasized. The environment should be conducive and the interview should be done under closed doors (Both, et al 2009). It is essential to be sensitive and respectful when discussing certain topics through observing of nonverbal cues. The interviewer should not give opinion and the interview should be confined within the scope. The last step is the formulation of a general picture whereby key points are summarized. The patient should also be given time to ask questions or to add more information on the topic of discussion.

During the interview, practitioners can ask open-ended questions. These questions require more than a yes or no answer to allow the practitioner to get data that are more detailed. Hypothetical questions are also used as they allow the practitioner to determine the knowledge of the patient and establishing whether it is accurate or not. Restatement or mirroring is also employed where the nurse states that which the patient said in ones own word (Both, et al 2009). The patients need to be encouraged to take the lead in the discussion. This allows solicitation of adequate information about the status of the patients. The patients should also be encouraged to provide additional information and to evaluate the situation. The use of critical thinking skills is also one of the effective interviewing techniques that can be used in the collection of health information. The nurse should encourage verbalization of the concerns, should mirror response, and restate the comments of the patient and verbalization what the nurse thinks the patient is implying.

Eliciting clients’ interpretations of health status, their perceived barriers and support is also essential when having an interview with them (Alspach, 2011). Some of the perceived barriers that may hinder the client from engaging constructively in the interview include communication problems, anxiety lack of assurance of privacy and confidentiality of information among others. The patients require better treatment and support to gain confidence by establishing positive relationships and assuming that their information will remain confidential. Patients too have their own way of looking at a problem or a health problem and it is essential to identify this. This can be interpreted by listening attentively and observing the patient closely. Close monitoring of non-verbal cues is also important when interpreting their health status. For example when maintaining eye contact with the patients, one will be able to tell those the patient is feeling or experiencing. A client suspected of being abused normally will speak in a guarded way, while a depressed patient will exhibit various symptoms such as fatigue, loss of appetite; lose of energy and profound sadness. Furthermore, client interpretation can also be known through asking of hypothetical questions.

To illustrate the various aspects or information that is sort for from a patient that makes up their health history, Andrew, one of my friends is adopted and suffers from depression. Andrew is a middle-aged person and has been involved in numerous conflicts with his neighbors on various issues relating to property ownership and threats of assassination. Signs and symptoms began in the last two months after he lost one of the properties he owned in a court due to lack of sufficient evidence. Andrew comes from an extended family and is married. He is a charming individual that socializes well with others. The last time he visited the health facility was a month ago. He was complaining of loss of appetite and sleep and general fatigue. Other information that he provided included whether he had taken an insurance cover or not and any other conditions or complication he had experienced. Andrew had no insurance cover and before his ailment, he had never been diagnosed with a disease. Andrew who was the chief complaint stated the significant symptoms and signs of his illness. Some of the symptoms and signs included difficulty in getting sleep, loss of energy and appetite, feeling of sadness and fatigue. Focused review of systems is an inventory of certain body systems that physicians carry out to identify the overlooked or forgotten symptoms in a patient (E/M University. (2013). Andrew was also taken through this process to help the practitioner to find out on aspects that he did not perceive to be part of his ailments such as measurement of his weight. Age, spiritual values and cultural variables are factors that were also considered during this interview. Andrew is a Christian and appreciates some cultural values. These variables influenced the interview because they could have in one way or another played a role in his health. For instance, age is taken into consideration when diagnosing depression. Depression is mostly prevalent amongst late adolescent’s middle-aged people and people that have already retired.

In conclusion, interview on health history of patient is important in helping practitioners to make appropriate decisions when it comes to treatment. During this interview, the relationships between the client and the practitioner should be enhanced. This increases the confidence of the client to share information with the practitioner. Listening and observing nonverbal cues is central to a successful interview. Other factors such as the family and the personal information about the client are important too.

References

Alspach, J. (2011). The importance of family health history: your patients’ and your own, Critical Care Nurse, 31(1): 10-15.

Both, W., et al. (2009). Medical Assisting. Chapter 36: Interviewing the patient, taking a history, and documentation, McGraw-Hill companies.

Brummel-Smith, K., & Halperin, A. (2013). Patient-Centered Care for People with Cognitive Impairment Is Possible in Primary Care, Generations, 7(3): 87-91.

E/M University. (2013). Review of systems. Retrieved from: http://emuniversity.com/ReviewofSystems.html