Taking a Patient's History - Book Report/Review Example

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 to clinical observation and testing as a means of diagnosing a patient. As Lloyd and Craig put it in the article, the art of clear communication will also go to great lengths in assisting a health practitioner to relate cordially with a patient to arrive at the right conclusion. In taking a medical history of a patient, Lloyd and Craig assert the importance of order and facilitating an appropriate environment.

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 systematic 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 patients’ privacy and dignity is the most appropriate one to do an assessment. Additionally, they advise that cultural aspects the patient is concerned with should always be respected. Using 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 the use of jargon. That use of non-verbal communications like nodding in approval and maintaining eye contact with the patient would go a long way to facilitate good communication with the patient, thereby facilitating assessment.

Another aspect of communication while handling a patient is 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 the 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 detail. 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 “How” so much while taking history. In many cases, your patient may suddenly become unresponsive or withhold some information back (Lloyd and Craig, 2007).

It is recommended that a patient gives an account from his own point of view. For example, asking a question like “what is the problem” to a patient sets one free to talk out what really bothers him. One thing that must be observed while taking a medical history is to watch out for symptoms and be attentive to the patient you were attending. The symptoms to watch against are those ones associated with general health, central nervous system, endocrine, gastrointestinal system, genitourinary system, gender-specific symptoms amongst the rest. All other categories of history should be taken using specific parameters and sequences that best assess them.

Evaluation of the article

As noted above, this article by Lloyd and Craig has set in a more summarized way of doing an assessment when taking a patient’s history. Arranged in a systematic way, Lloyd and Craig try to address the need for simplified guidelines for health practitioners in an attempt to improve services in the field of healthcare. In a clever way, the writers have also drawn close relationships between ethics, culture, and nursing competence as fundamental issues that need to be put into consideration by health practitioners.