Nursing practice is evolving and nurses today are expected to be familiar in history taking and be professional always about how they do it. This article gives tips on how a comprehensive and complete history can be taken by nurses who are increasingly being delegated this important aspect of health care delivery.
The authors give out steps to take during history taking so that it is systematic and all essential information obtained (including sensitive information). The nurses must be careful not to divulge confidential personal information and also make sure that there is prior consent obtained to get personal information related to history taking. Nurses must make sure that the environment in which they take information is appropriate and comfortable to the patient and additionally, they must establish rapport with the patient by making all appropriate verbal and non-verbal communication gesture. Some nursing experts prefer taking history in a set pattern or sequence but this is not very important. What is crucial is that all the needed information is obtained to get a comprehensive picture of the patients past and present health status.
Communication is important to gain the patients trust so even the manner of how the questions are phrased or asked should be considered. Questions can be open-ended but nurses can ask more specific questions later on to clarify some information and make sure they got it right. Accuracy is crucial as the health assessment will serve as the basis for the doctor when making a diagnosis and when considering the course or type of treatment that is appropriate. The authors took extra efforts to present their ideas in an easily understandable manner, even placing important points inside a box such as appropriate communication skills, the desired sequence in taking history and listing by category using major body systems the usual kind of symptoms each body system will present if