Taking a patient history: the role of the nurse literature review

Introduction

The article that formed the foundation of this analysis is “ Taking patient history: the role of the nurse” by Tonks Fawcett T and Sarah Rhynas. The article was published in 2012 under the Nursing Standard Journal. The article examines the importance and skill in taking the history of patients before they are examined for ailments. In the contemporary nursing care provided, history taking, coupled with the right communication skills is what makes nursing care complete. The article goes into depth about the how the care is planned, the process of assessment and the how history taking facilitates all these aspects that are involved in the provision of care.

Summary

The reading identifies the traditional forms of assessment in nursing as not being keen on the aspect of history taking. As the radical field of nursing grew from the 1970s, history taking became part of the mandatory process in planning, assessing and examination of patients. There has been the adoption of patient-centered care in caregiving. The system is where the patients’ needs receive a profound priority. Because of this approach, nurses have had to shape their communication skills and foster rapports with the patients. The process of history taking is demanding of their communication skills because it seeks to know the experience of the patient in relation to the sickness. It goes beyond simple note taking to incorporate personal questions and the feelings of the patient. Additionally, it takes a professional account of finding information, where the help of relative and caregivers in incorporated. Traditionally, care was given based on clinical notes.
Contemporary patient-centered care observes the individual as a whole person and therefore uses history taking to understand all the spheres that will be necessary for caregiving. It gives the nurse a better understanding of the individual, which is the main aim of patient-centered caregiving. The article identifies the effectiveness in which nurses can acquire knowledge by indulging patients about their histories. Some diagnoses need a strong basis of knowledge that can only be provided through a person’s history. Furthermore, the process of sharing information is therapeutic to the patients who need coping mechanisms for their situations. It does beyond formal acquisition of knowledge through admission reports and focuses on psychological and social factors of a problem that might result in the nurses acquiring aesthetic knowledge (Fawcett & Rhynas, 2012). The authors identify long-term care, where history taking in this approach goes to a wider scope. Here, a rapport with the patients and their families is mandatory. The information gathered when a patient fills a sheet act as a starting point of history taking. Moreover, taking histories of the patients helps in the identification of factors that may help relieve the pressure of long-term hospitalization. From the histories, the patients can be understood and become more comfortable when they are hospitalized. The article also identifies the challenges in the acquisition of the histories of patients. The process is dynamic in nature and might often be confusing for both the practitioner and the patient. There is a challenge in not knowing what questions to ask and a nurse lacking confidence in oneself. The article concludes by citing communication as a paramount factor that fosters the taking of history notes from patients.

Evaluation

The article clearly explains what the process of taking history notes from patients mean. For an individual with no prior knowledge on the subject, the article does offer good insight into this perspective of improving patient care. It looks at the subject in an easy way, and explains it from an angle that is easy to understand and relate to. The article introduces known concepts such as patient-centered care to explain a subject that has gone through an adequate critical analysis from medical practitioners. Through the use of the common concepts, the practitioner can understand the depth of the concept of taking history notes from patients. Furthermore, it takes the readers through the comprehensive analysis of how nursing care was traditionally, and enables them to see the value of taking history notes. However, the article lacks depth in the identification of the challenges faced by taking history notes from patients. There are many potential challenges that the article fails to identify. For example, patients and family might fail to open up or give conclusive histories. The article only identifies surface challenges that the process could encounter. Also, it would help if the authors clearly identified ways through which nurses can improve their skill in history note taking. The article only cites good communication and help from a mentor as ways that can foster history note taking. Since the practice is still being incorporated into the health systems, practitioners would benefit from the knowledge on how to improve their skills.
Even so, the article was of great interest me. It observed the roles played by the family, patient and health practitioners in the process of giving care and assessments from a new angle. It is fascinating to note how the process of knowledge acquisition involves all the three parties and the information they give. In a nutshell, the authors influenced my new thinking on the process of caregiving. It goes beyond the traditional forms of care to which people are accustomed. Caregiving is explained as a complex phenomenon that entails substantially more than meets the eye. Furthermore, I was interested to learn on how the taking history notes affects diagnosis of an ailment. The article was fascinating to that extent, where it showcased that the process of accurate examination and diagnosis begins with the taking of history notes. The health assessment strategy proved to be beneficial in the healthcare setup, and every practice should adopt it. It was well explained in a manner that showed that it is easy to incorporate into the system and does not require a specialized framework for its effectiveness.
More conclusive research into this method of health assessment must be done. The benefits accrued to history note taking will facilitate the process of patient-centered care and lead to accuracy and proper diagnosis. Based on this, it is important that other scholars do more research on the subject and provide more comprehensive reports on the subject because it will improve healthcare. The information would benefits patients that are involved in long-term care. Knowledge on patient history would be helpful for those who suffer from chronic illnesses and other serious medical issues because they are in need of the continuous medical attention. Older people, especially, would benefit from this kind of assessment in healthcare systems.
Conclusion

Reference

Fawcett, T., & Rhynas, S. (2012). Taking a patient history: The role of the nurse. Nursing Standard, 26(26).