A Guide to Taking a Patient's History Name of Student: of Institute: Abstract This paper is a review and analysis of A Guide to taking patients history as presented by H. Lloyd and S. Craig. The paper addresses issues around nursing standards and healthcare management for matters related with clinical observation and testing as a means of diagnosing a patient…
Introduction Lloyd and Craig suggest that the most important thing to do while preparing to conduct an assessment on a patient is to prepare the environment. They advise on following procedures as it helps the patients to give an account of their problem, some of which nursing assessment cannot arrive at successfully. As skilled and experienced practitioners, Lloyd and Craig proceed to give an outlined, sequential, and systematical way of conducting the medical history of a patient. Together, both Lloyd and Craig underscore the importance of a medical practitioner and developing a closer personal relationship with a patient as the patient is being taken through a systematic assessment of history taking. Summary of the Article In making an appropriate environment, Lloyd and Craig advise that it is of fundamental importance to assess the environment to see if the patient is comfortable with the whole setting. They advise that the kind of environment that will preserve patient’s privacy and dignity is the most appropriate one to do an assessment. Additionally, they advice that cultural aspects the patient is concerned with should always be respected. Using a clear, concise and easily understandable language is recommended. The purpose of a medical assessment is to get feedback; therefore, the communication aspect should override any complexity that may be posed by high proficiency and use of jargons. That use of non-verbal communications like nodding in approval and maintaining an eye contact with patient would go along way to facilitate good communication with patient, thereby facilitating assessment. Another aspect of communication while handling a patient is the tone. Lloyd and Craig observe that addressing patients using the right tone is a good communication habit. Additionally, a practitioner should always get consent from a patient before embarking on any check up or assessment. Just before the assessment on history taking begins, it is advisable to make an introduction of yourself and find out how your patient would like to be called. Scholars have advised that history-taking process should be sequential (Lloyd and Craig, 2007). The review notes that different ways of gathering information can be used to gather a patient’s medical history. For instance, an open-ended question can be used before finally asking questions on the assessment areas not covered. That to be sure, it is also recommended that a practitioner summarizes the whole history back to the patient for purposes of clarification. Another aspect of history taking from a patient that Lloyd and Craig advice is that history taking sequence should be in this order: present complaint, past medical history, mental health, medication history, family history, social history, sexual history, and occupation history. A systematic inquiry is always of great essence. Point often overlooked is counter-checking the history with your patient after you have recorded it down so that both the practitioner and the patient are in agreement about the information collected. During taking of a patient’s history, each symptom should be explored in details. It has also been noted that sometimes, inappropriate history collection method that is unethical may occur. It is therefore advisable to avoid asking questions like “ ...
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