Chapter 2: Obtaining a Health History
Learning objectives for this chapter
By the end of this chapter, we would like you:
-To explain the place of the health history in the health observation and assessment process.
-To discuss the different types of health histories, and their uses in different clinical contexts.
-To list the components of a comprehensive health history.
-To explain the use of therapeutic communication and rapport in the health history interview.
-To describe the importance of effective questioning, and the use of a variety of interpersonal skills and communication techniques, in the health history interview.
-To describe the various barriers and challenges to effective communication in the health history interview, and effective responses to these to facilitate data collection.
The health history
Health observation and assessment involves three concurrent steps:
The focus of this chapter is the health history. This involves collecting subjective data - that is, data about a patient's symptoms. A variety of other important information is also collected during the interview - including information about a person's health-related values, beliefs and attitudes, their current health-related practices, the socioeconomic, cultural and other factors impacting on their health, and their willingness and capacity to make health-related changes. Data is collected via an interview with the patient and / or significant others. Data collected at this stage may be primary or secondary. In acute situations, the patient's health history may be communicated by another health care provider.
The nurse's role in the interview process is to: (1) facilitate discussion to collect health-related data, and (2) record this data. Data collected during a health history interview informs both the subsequent physical examination of the patient and also the health care which is provided to that patient.
In many clinical settings, patients are asked to complete a questionnaire as part of the process of collecting their health history. Health history questionnaires typically consist of a series of simple yes / no questions, often related to the specific symptoms and risk factors associated with common disease. It is important for nurses to realise that health history questionnaires do not replace or preclude the need for the health history interview.
Types of health histories
It is important for nurses to note that there are a number of different types of health histories which may be collected from a patient:
- A comprehensive health history. This collects detailed information about a patient - including their biographical data, present health status, past medical history, family history, personal situation and a review of all body systems.
- A rapid or focused health history. This collects specific information about a clear health-related issue or need with which a patient presents.
The type of health history collected from a patient depends on: (1) the context in which the patient has presented, and (2) the patient's health care issues and needs.
Components of a health history
A health history interview typically consists of three distinct sections: (1) introduction, (2) discussion, and (3) summary. Each of these sections is described following:
All health history interviews begin with the nurse introducing themselves to the patient and explaining their role in the provision of the patient's health care. Nurses explain why the interview is being conducted, and also the processes involved. The aim of this explanation is to prepare the patient and to enhance their comfort in sharing health-related information.
The next section of the interview is where the nurse focuses on facilitating discussion with the patient to collect health-related data. The nurse uses a range of questioning and other communication techniques to collect the information required to inform the physical examination and the subsequent provision of the patient's health care.
The nurse focuses on collecting the following information:
- Biographical information
- Reason for seeking health care
- History of presenting illness
- Present health status
- Past health history
- Family history
- Personal and psychosocial history
- A review of the patient's body systems
It is important to highlight that many health care organisations have standardised templates which nurses can use to guide their collection of this data during a health history interview. Nurses must ensure they are familiar with these templates and how they are expected to apply them in practice.
The final section of the interview is the summary section. Nurses should summarise the key data collected during the interview and the patient should be encouraged to clarify any errors or inaccuracies. Although it is brief, the summary section of the health history is important because it provides a patient with a sense of validation that the nurse understands their health issues and needs.
Therapeutic communication and rapport
Therapeutic communication focuses on developing rapport with a patient - that is, a trusting relationship which facilitates their comfort in sharing personal information. There are a number of important factors which impact on the development of rapport in the health care setting:
- Privacy is crucial in facilitating a patient's ease in discussing personal information. Patients may be unwilling to share sensitive information in an open and honest way if they are fearful of being overheard by others. Ideally, health history interviews are conducted in private examination rooms, however this may not always be possible. The nurse should carefully consider whether the presence of the patient's family or significant others is appropriate during the interview.
- The location in which an interview is conducted should be quiet and free from distractions. Interruptions should be avoided to the greatest possible extent. Any unnecessary equipment in the interview space should be turned off and removed if possible. Nurses may consider placing an 'Interview / Examination in Progress' sign on the door or curtain to discourage interruptions.
- To facilitate a patient's ease in discussing personal information, they must also be physically comfortable throughout the interview. Wherever possible, the nurse should allow patients to remain in their own clothes for the interview. The nurse should sit at a distance and angle from the patient which respects their personal space. When planning for the patient's comfort, the nurse should also consider the seating provided, the temperature and lighting of the room, and the patient's access to water and toilets.
- The nurse's demeanour should be professional yet warm, and they should practice a variety of interpersonal skills to develop rapport. The nurse should focus on the patient, and on understanding the patient's experiences and perspectives, without interruption, judgement or interpretation. The nurse must demonstrate a genuine interest in the patient, treat the patient with acceptance and respect, and focus on the patient's individual health-related issues and needs.
- Patients who are very physically or psychologically unwell, who are experiencing extremes of emotion, or who are otherwise uncomfortable may not be able to participate effectively in a health history interview. In these situations, nurses should focus on collecting only the data required to provide immediate care, and return to complete a more comprehensive health history interview when the patient is more prepared to participate.
Questioning, interpersonal skills and other communication techniques
Questioning is a key communication skill used by nurses during the health history interview. Questioning occurs in two equally-important parts: (1) asking the patient for information, and (2) listening carefully to the patient's response. There are two key types of questions a nurse may ask during a health history interview:
- Open-ended questions. These are broadly-stated questions which encourage a detailed multi-word response.
Open-ended questions are useful when a nurse wishes to collect general data about a patient's symptoms, their health-related values, beliefs and attitudes, their current health-related practices, the socioeconomic, cultural and other factors impacting on their health, and their willingness and capacity to make health-related changes.
- Closed-ended questions. These are specific questions which encourage a one- or two-word answer.
Closed-ended questions are useful in collecting information about a specific topic, to clarify information gathered during open-ended questioning and in urgent situations where information is required rapidly.
In addition to questioning, there are a variety of other communication strategies a nurse should use when collecting data from a patient during a health history interview. These skills include:
- Acknowledgement and encouragement
- Active listening
When communicating with patients, it is important for nurses to realise that people are not always direct in saying what they mean. Nurses must be conscious of picking up on 'cues', or subtle hints which suggest the patient may have an underlying concern they are finding difficult to discuss. There are a number of cues seen commonly in health care settings:
- A patient may use indeterminate statements.
- A patient may use neutral statements.
- A patient describes psychological symptoms.
- A patient is unclear or evasive about the symptoms or concerns they experience.
- A patient may be vague or indirect when answering questions.
If a nurse identifies one of these cues, they should question the patient in a respectful and sensitive manner to further explore the topic.
There are also a number of general strategies nurses should use when questioning patients during a health history interview:
- Questions must be clearly spoken.
- Avoid medical language / jargon.
- Use terms and phrases familiar to the patient.
- Adapt questions to the patient's own level of knowledge.
- Encourage patients to be specific / detailed in their responses.
- Ask one question at a time.
- Be attentive to the patient's reactions / feelings.
- Explain the need for asking about sensitive topics.
Barriers to effective communication
It is important for nurses to recognise that there are a variety of barriers that diminish the quality of the data collected during a health history interview. The key barriers are described in the following section:
- Use of medical terminology / jargon.
- Expressing value judgements.
- Interrupting the patient.
- Being authoritarian or paternalistic.
- Using 'why' questions.
It is important to note that there are a variety of other challenges a nurse may encounter when completing a health history interview. For example:
- The patient asks the nurse a personal question. In some situations, it may be appropriate for a nurse to briefly share a personal experience, however the focus of the interview should be rapidly directed back to the patient.
- The patient is silent in response to a question. Allowing the patient to be silent for a short period can be useful, as it allows them time to gather their thoughts and plan a response.
- The patient displays emotion. The nurse should acknowledge the patient's emotion, and allow the patient to experience it.
- The patient is overly-talkative. This can result in the collection of large amounts of irrelevant data, whilst important data may be overlooked. Nurses should tactfully redirect the conversation, and use closed-ended questions.
- The patient speaks a language other than English. In this situation, nurses have a responsibility to access the services of a qualified health interpreter.
This chapter has introduced the knowledge and skills required by nurses to collect a comprehensive health history from a patient. It began with an explanation of the place of health history in the health observation and assessment process, a description of the different types of health histories and their uses, and an overview of the components of a comprehensive health history. This chapter went on to explain the importance of therapeutic communication and rapport in the health history interview, and the use of questioning, interpersonal skills and other communication techniques to facilitate data collection. Finally, this chapter considered the variety of barriers and challenges to effective communication in the health history interview, and how nurses can respond effectively to these.
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