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Essay / The Importance of Taking an Accurate Medical History
Introduction “A Guide to Taking a Patient History” is an article published in Volume 22, Number 13 of the Nursing Standard Journal in December 2007, written by H. LLCyd and S. Craig. . The article talks about the steps and strategies to follow when taking a patient's history. It is important to learn good patient assessment techniques starting with the environment, communication skills and a systematic approach. One must be able to collect accurate data in order to facilitate the procedure.SummaryThe article begins by emphasizing the environment when taking a patient's history. The environment must be safe for the patient and the nurse. The environment should be quiet and ideally there should be no interruptions (LLoyd and Craig, 2007). For proper collection of patient history, the environment should be prepared well in advance. An important issue identified in the article is communication as the basis for managing the history taking process. For adequate communication to be established between the patient and the nurse, there must be sufficient interaction between the two. Verbal and non-verbal skills are required. Questions should not be judgmental. Open-ended questions provide more general information about the patient. The Calgary Cambridge framework is one of the methods used. The nurse should treat the patient with respect and dignity and make every effort to maintain confidentiality. Additionally, the patient needs time to provide a complete history. It is best to avoid technical terms that the patient may not understand. It is important that the nurse speaks clearly to avoid confusion. Before starting the process, the patient's consent is required. It is also important to ask the patient about their health beliefs and practices. Once the general structure of the history is established, one can begin to ask questions about the presenting complaint, medical history, mental health, followed by medication history. It is important to ask about any over-the-counter medications and herbal remedies the patient is currently taking. Family history is also a good tool for collecting patient history. The patient's social history should also be included, as well as their sexual history and work activities. The nurse should gather information about other body systems that are not covered at the beginning of the assessment. This will reduce the risk of omitting important information. The evaluation of the article Lloyd and Craig (2007) identified crucial features in the patient history, for example: an appropriate environment, effective communication and procedures involved in the patient history process..