History taking
Taking a history from a patient or service user is key to nursing roles in a variety of clinical settings. A complete history is necessary for the nurse to conduct an assessment, come to a valid diagnosis or generate a care and support plan.
Article by Peter Ellis
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Purpose
Taking a history from a patient or service user is key to nursing roles in a variety of clinical settings. A complete history is necessary for the nurse to conduct an assessment, come to a valid diagnosis or generate a care and support plan (Ellis and Standing, 2023).
The Nursing and Midwifery Council requires that ‘people’s physical, social and psychological needs are assessed and responded to’ (Nursing and Midwifery Council, 2018), and a key part of this assessment process is taking the patient’s history.
The National Institute for Health and Care Excellence (NICE) (2018) states that patients have the right to have an advocate present at a care planning assessment to ensure that their wants and needs are met.
Definition
Taking a history from a patient is distinct from collecting physical data (eg measuring blood pressure, pulse rate or undertaking a physical examination), but is an equally important and complementary procedure. Taking a history involves collecting verbal data from the patient regarding their reason for visiting the healthcare facility. A thorough history may provide up to 80% of the information needed to make a clinical diagnosis (Diamond-Fox, 2021).
The nurse must first determine whether the patient needs to undertake a comprehensive or focussed assessment (Hogan-Quigley and Palm, 2021). A comprehensive assessment is appropriate if the patient is new to a care setting and a history of their care needs is required (Fawcett and Rhynas, 2012). A more focussed assessment might take place if the patient is returning to a care setting in which they are an established patient or, for example, if they are visiting an emergency department with an acute problem (Hogan-Quigley and Palm, 2021). In the latter case, a rapid assessment using the ABCDE approach should be conducted (Smith and Bowden, 2017):
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Communication
Establishing a rapport with the patient, explaining the process and getting consent are fundamental to taking a patient’s history (Ingram, 2017). A simple question such as, ‘are you happy for me to take a history from you so I can better understand your needs?’ not only establishes consent, but also serves to put the patient at ease and build trust and confidence (Donnelly and Martin, 2016).
Communication is not only about asking questions but, as Lowth (2015) points out, is also about careful listening, particularly as this will allow nurses to make an accurate diagnosis based on the patient’s description of their symptoms. It is often best to ask a combination of broad, usually open questions, allowing the patient to describe their experiences and needs in their own words (Lowth, 2015), alongside more focussed, closed questions aimed at gaining a better understanding of the presenting symptoms (Ventres and Frankel, 2015). Using a combination of communication strategies means that the nurse is less likely to miss details of the patient’s condition (see Communication).
Examples of open questions include:
- In your own words, can you describe the pain to me?
- In your own words, can you describe how you feel?
- In your own words, can you describe your symptoms?
Examples of closed questions include:
- Did the symptoms start gradually or quickly?
- How often do you experience symptoms?
- What makes the symptoms better?
Closed questions are often used to gather more detail on the answers to the open questions.
Structure
There are a number of structures or models which can be applied when taking a history. The most common of these are explored here, along with some of the mnemonics used to aid in holistic and consistent data collection (Diamond-Fox-2021). Structured history taking, often coupled with a structured physical examination, are important foundations to inform decision making about care provision (Donnelly and Martin, 2016).
Presenting complaint
It can be useful to begin history taking by understanding why the patient has come to the appointment, in their own words. Open questions at the start of the consultation, such as ‘what have you come to see me for today?’ enable the patient to make their healthcare concerns clear (Lowth, 2015). Sometimes this is enough for the nurse to understand the issue that the patient is presenting with.
The literature often alludes to the ‘golden minute’ when it comes to patient assessment and history taking (Sidebotham, 2019). This first minute of the consultation can be used to allow the patient to talk freely about why they attended the appointment, and the nurse can, while actively listening, also use this time to observe the patient for visual clues about their condition.
History of presenting complaint
Understanding the salient features of the presenting complaint is important for diagnosis as well as understanding the impact of the issue on the patient. Frequently used mnemonics for structuring questions include OPERATES and OLD CART:
- Onset of complaint – when did it start?
- Progress of complaint – how has it changed over time?
- Exacerbating factors – what makes the symptoms worse?
- Relieving factors – what makes the symptoms better?
- Associated symptoms – what else do you feel?
- Timing – when do the symptoms present and for how long?
- Episodes of being symptom free – when are you free of symptoms?
- Relevant Systemic and general inquiry – for example, using a pain scale to determine level of pain (Diamond-Fox, 2021)
- Onset – when did it start?
- Location – where are you affected?
- Duration – how long do the symptoms last?
- Characteristics – what are the symptoms like?
- Associated factors – what else have you experienced?
- Relieving/aggravating factors – what makes the symptoms better/worse?
- Treatment – what have you tried that helps? (Tagney and Younker, 2012)
Other scales or mnemonics can be used to understand specific symptoms, for example, asking the patient to grade their pain on a scale of 1-10 or discerning the nature of their pain using the SOCRATES mnemonic:
- Severity – use a pain scale
- Onset – when did the pain start?
- Characteristic – what is the pain like?
- Radiation – does the pain spread to anywhere?
- Additional factors – what makes the pain better?
- Time – is it always painful, when did it start and does it last all day?
- Exacerbating factors – what makes it worse?
- Site – where do you experience the pain? (Chapman et al, 2021) (See: Pain levels)
Medications and allergies
While the nurse may be able to get a list of medications that a patient is prescribed from their GP, nurses must also ask about over-the-counter medication use (eg painkillers) as well as alternative therapies, homeopathy (Peart, 2022) and illicit drugs. The nurse may need to be knowledgeable of proprietary names for medications which patients may use.
It is important to understand allergies and their impact on the patient, as this may affect the choices for treatments (eg use of non-penicillin antibiotics) as well as any medications previously used to manage the presenting condition (Nickless and Davies, 2016).
Family history
The nurse may need to apply some discretion when asking questions about family history (Peart, 2022). In many cases, the family history of a patient may be irrelevant, depending on the condition they are presenting with (eg a fracture from slipping on ice would not require a family history).
Family histories can be explored using diagrams (Tagney and Younker, 2012) and may help to clarify the cause of a particular set of symptoms (eg a family history of diabetes, depression or kidney disease).
Social history
As many diseases are related to lifestyle choices and behaviours (Peart, 2022), taking a social history can be useful, considering behaviours such as:
- smoking
- alcohol use
- drug use
- occupation
- recent travel history
- household status
- hobbies (Tagney and Younker, 2012; Diamond-Fox, 2021)
Any of these may provide insight into the cause or severity of a presenting condition.
What matters to the patient?
It is important for the nurse to ask the patient what they think is happening and what they want to gain from the consultation (Peart, 2022). Some fundamental questions might cover if the person has suffered similar symptoms before, what the diagnosis was then and what helped manage the problem. The nurse can use the patient’s understanding of their symptoms in combination with a comprehensive history to reach a diagnosis.
Documentation
It is crucial to document the information gained from taking a patient’s history, not only to produce a record of the interaction, but also ensure the process is comprehensive and focussed (Ingram, 2017). Documentation is fundamental to continuity of care and monitoring process. Additionally, following a recognised process of questioning means the patient may avoid having the same questions asked of them by care professionals in the future (Asmirajanti et al, 2019).
Resources
Asmirajanti M, Hamid AYS, Hariyati RTS. Nursing care activities based on documentation. BMC Nurs. 2019;18(1):32. https://doi.org/10.1186/s12912-019-0352-0
Chapman S, Carvalho F, Dinen C. Pain Assessment and Management. In; Lister S, Hofland J, Grafton H, Wilson C (eds.). The Royal Marsden Manual of Clinical Nursing Procedures (10th edn). Chichester: Wiley Blackwell; 2021 pp. 457-496.
Diamond-Fox S. Undertaking consultations and clinical assessments at advanced level. Br J Nurs. 2021;30(4): 238-243. https://doi.org/10.12968/bjon.2021.30.4.238
Donnelly M, Martin D. History taking and physical assessment in holistic palliative care’. Br J Nurs. 2016;25(22):1250–1255. https://doi.org/10.12968/bjon.2016.25.22.1250
Ellis P, Standing M. Patient Assessment and Care Planning in Nursing. 4th ed. London: Sage. 2023.
Fawcett T, Rhynas S. Taking a patient history: the role of the nurse. Nurs Stand. 2012;26(24):41-48. https://doi.org/10.7748/ns2012.02.26.24.41.c8946
Hogan-Quigley B, Palm ML. Bates' nursing guide to physical examination and history taking. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. 2021.
Ingram S. Taking a comprehensive health history: learning through practice and reflection. Br J Nurs. 2017;26(18):1033-1037.
Lowth M. History taking for the practice nurse. Practice Nurse. 2015;45(7):14-18.
National Institute for Health and Care Excellence. What to expect during assessment and care planning. 2018. https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/what-to-expect-during-assessment-and-care-planning (accessed 25 April 2023)
Nickless G, Davies R. How to take an accurate and detailed medication history. Pharmaceutical J. 2016;296:7886. https://doi.org/10.1211/PJ.2016.20200476
Nixon V. History Taking in In Professional Practice in Nixon V. (Ed.). Paramedic, Emergency and Urgent Care. Wiley and Sons: Oxford. 2013.
Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 25 April 2023)
Peart P. Clinical History Taking. Clinics in Integrated Care. 2022;10:100088. https://doi.org/10.1016/j.intcar.2021.100088.
Sidebotham CE. Observation: what do you see? Br J Gen Prac. 2019;69(688): 559. https://doi.org/10.3399/bjgp19X706337
Smith D, Bowden T. Using the ABCDE approach to assess the deteriorating patient. Nurs Stand. 2017;32(14):51-63. https://doi.org/10.7748/ns.2017.e11030
Tagney J, Younker J. Clinical skills: history taking in cardiac patients. Br J Cardiac Nurs. 2012;7(12): 588-594. https://doi.org/10.12968/bjca.2012.7.12.588
Ventres WB. Frankel RM. Shared presence in physician-patient communication: A graphic representation. Families, Systems, & Health. 2015;33(3):270–279. https://doi.org/10.1037/fsh0000123