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Hillary Lloyd, a principal lecturer in nursing practice, development, and research, and Stephen Craig, a senior lecturer in nursing, presented a study under the title “A Guide to Taking a Patient’s History”. The article was published in the journal the “Nursing Standard” in December, 2007. The article, that contains a practical guide to taking a history using a systemic approach, became a weighty contribution to the vast volume of researches devoted to the urgent issue of patient’s health effective assessment.
Summary of the Article
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The article is focused on the process of taking a patient’s history from by a nurse. The stress is put on the preparing the environment, communication skills, and the importance of order in the process of taking a history from a patient. H. Lloyd and S. Craig pointed out that taking a patient’s history is the most important aspect of patient’s assessment. Numerous studies were cited in relation to and support of the study. The authors frequently referred to the researches of Grumbie (2006), Grouch and Meurier (2005), Kurtz et al (2003), and Douglas et al (2005).
The authors stated that preparing the environment, as the first part of any history taking process, should include an “accessible, appropriately equipped, free from distractions, and safe for the patient and the nurse” place, respect for the patient, and sufficient time to complete the history. Another key point, the authors stressed, concerns communication items: manner of information gathering, essential communication and listening skills, developing a rapport and nurse’s language. Examples of non-verbal and verbal communication skills were provided in box 1. The authors discussed the technical and legal information of the informed consent gaining from a patient.
The general principles of the history taking process such as introduction, order and structure, the use of open and close questions, and clarification were discussed in details. A brief summary of a history taking sequence was presented in box 2. H. Lloyd and S. Craig suggested Calgary Cambridge Observation Guide as an ideal model of the consultation. Five stages for history taking summarization, proposed by Kurtz et al, are mentioned: explanation and planning, aiding accurate recall and understanding, achieving a shared understanding, planning through shared decision making, and closing the consultation. The authors included the box with cardinal symptoms which could come in handy greatly to lead the systemic enquiry.
The key point of the article, the structure of the history taking advised by Douglas et al (2005), was discussed in details. The authors thoroughly analyzed the issues of presenting complaint, past medical history, mental health, medication history, family history, social history, sexual history, occupational history, and systemic enquiry. Special attention was paid to the social history elements of alcohol, smoking, and illicit drugs problems, supported with figures and interesting facts about the CAGE system, equivalent units of alcohol, and approximate calculation of tobacco, provided in boxes 5, 6, and 7.
H. Lloyd and S. Craig concluded that the best method of achieving skills in history taking is through a validated training course with competency-based assessments and the novice history taker's records should adhere to the NMC's (2007) guidance on record keeping.
Evaluation of the Article
As any other journal article “A Guide to Taking a Patient’s History” by H. Lloyd and S. Craig has its strengths, weakness, and notable features. Among the strengths of the article is the manner of material presentation, which is effective and comprehensive. The authors presented the most important information and interesting facts in 7 boxes within the text. Such a technique of the material giving catches the reader’s attention, contributes to better memorizing of the most important items. They chose the best way for a practical guide to be written, because in such a way they achieved their main objective – to familiarize the reader with the key points required in taking a comprehensive patient’s history and to teach how to do it effectively. The sub-headings helped to understand how the author organized the content. So, the health assessment strategy was explained clearly enough and the authors coped with their tasks.
The authors maintained neutrality in their choice of words and terms. They did not define any terms, just specified what concepts are included in the discussed category. The effect of the authors’ objective language is achieved through appropriate vocabulary and sentence structure.
Sufficient references section of 27 items was proposed. The authors included the most important researches in the analyzed field, because they are frequently quoted in other studies of the same sphere. A half of the works in the references’ list was recent enough and was used to support the authors’ claims and ideas.
The article interested me, because a great deal of the most important information concerning the history taking process can be find on the pages of the analyzed study. Moreover, I met some interesting facts about social history gathering that I had not heard before. The health assessment strategy proposed in the article is beneficial and it should be adopted in my practice in order to become more successful in my career. The useful practical recommendations about helpful and unhelpful techniques that were provided in the article could be successfully employed in the nurses’ everyday practice. The examples of possible questions for history taking process could improve medical workers’ communication skills. The authors suggested the areas for further discussion, which pertained to “NMC Code of Professional Conduct” regarding competence, consent and confidentiality and the “NMC's guidance on record keeping”.
Despite all the strong aspects of the article there are some points that could have been improved in the analyzed study. The objectives of the study could have been stated more definitely and clear. Very few examples of statistical data were suggested in the text. The content of the article would have more impressive and effective influence upon the reader and would be more interesting if more figures of statistics concerning the discussed problems had been mentioned. New research articles should be written about this area of health assessment provided with statistics pertaining to the participants, their sociolinguistic characteristics, psychology, and pragmatics of history taking process. One more tiny remark concerning the general impression of the proposed practical guide should be mentioned. The systemic and logical approach to taking a patient’s history presented in the article looks like ideal one. Medical workers are limited in time in their everyday encounters with patients. That is why there is no possibility to perform all the recommendations proposed by the authors. Nevertheless all the strong sides of the article far overweight its weak sides, which are very few.
Thus, a framework for taking a full and comprehensive history from a patient was provided in the analyzed article. The authors simply revisited the information that was already known in the field, summed up, and structured it. Though the article does not contain any “breakthrough” information, its significance reveals in the summarized presentation of the most important issues in the field of medicine that pertains to the history taking process and effective practical recommendations for nurses. The article is organized logically and easy to follow. The used charts are effective in presenting information. H. Lloyd and S. Craig successfully achieved their goals in the analyzed study. Medical workers, especially nurses, and students of medical and nursing faculties would benefit the most from information reported in this article.
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