A comprehensive history-taking is crucial for healthcare professionals, like advanced nurse practitioners, as it helps in understanding the patient's health status, identifying potential risk factors, and guiding further diagnostic and treatment decisions. It often follows a structured approach to ...
The ability to gain an accurate clinical history from patients is crucial to safe diagnosis and t
diagnoses can be reached through the history alone. With any clinical presentation, it is esse
knowledge to clinical management. Physical examination and diagnostic investigations serv
history.
History taking is an integral element of overall clinical management. It is a skill to be able to
history. Often, the patient is telling you the diagnosis. The skill is in allowing time, building
patient. Conversation will be more fluent by encouraging mutual respect, by instilling confid
communication. Active listening will help lead to an initial diagnosis. Be careful to avoid b
incorrect conclusions when gathering a patient history. This may lead to an incorrect diagno
lead to a lack of trust and a break-down in communication.
It is important to appreciate that eliciting a comprehensive clinical history sits within consul
Cambridge consultation guide (Kurtz and Silverman 1996) encourages allowing time to esta
effective communication. It adopts a person-centred approach combined with emphasis on a
approach to the consultation ensures that there is a balance of power rather than the outdated
In this webpage we will focus on the key steps in gathering a person-centred clinical his
patient. While the format below provides a useful outline strcuture to follow it it is importa
tasks or tick boxes. You have probably observed colleagues who adapt their questioning so t
are having with the patient. At the end of the interview the clinician can mentally check tha
before structuring the history into the traditional 'medical model' within patient's notes. It is
‘targeted clinical histories’ but do try to take opportunities to take a ‘full history’.
Being person-centred
It is vital to take time where possible to consider the patients’ personal belief and experience
they feel about it? Have they previous experience of illness, either personally or through a lo
Innes, Dover and Fairhurst (2018) explore patient’s ideas, concerns and expectations (ICE
o Ideas – Explore the patients’ ideas and feelings about their illness. Possible impact on
their ability to provide or care for others? Impact of being able to enjoy sport and recrea
o Concerns - Do they have a preconceived fear of illness, diagnosis, or treatment? Are t
serious diagnosis or concerned a serious diagnosis may be overlooked? Are they playin
a hospital admission? Or are there any other hidden agendas that you might be missing
modality or admission to hosptial. Other infuencers might be that they are a burden on
o Expectations – Of assessment, diagnostic testing, treatment, management, and follow
to the consultation? Do they have an expectation of what will happen based on their ow
experience of others?
It is also vital to consider how patient's symptoms are affecting their day-to-day life, includi
ability to work etc.
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