History taking for the practice nurse

Taking a history is a crucial part of any consultation, but not all of us have natural aptitude for the listening and communication skills that are essential to effective history-taking

'Listen to your patient, he is telling you the diagnosis.’

These are the words of William Osler, a Canadian physician at the turn of the last century who has been called the father of modern medicine,¹ and they sum up the art of effective history taking.

Practice nurses are increasingly involved in seeing unselected patients in primary care. Taking a history is a crucial part of any consultation, both to allow the nurse to gather the information that makes the encounter medically useful, but also as a means of opening communication with the patient in order to make them a partner in their own management.

History taking aims to

• Establish rapport
• Understand what the patient is experiencing
• Compare that against your knowledge and experience
• Formulate a likely diagnosis and a differential diagnosis
• Understand their ideas, concerns and expectations

It can also help to think of the process as gathering two kinds of data:

• A clear picture of the problem from the patient’s point of view
• A clear picture of the problem from your medical point of view

WHAT SKILLS ARE NEEDED?

Good history taking needs

• Communication skills to build rapport and ensure understanding
• Ability to listen and respond
• Clinical knowledge including
  • Knowledge and experience of common conditions and presentations
  • Knowledge of and alertness to uncommon but important conditions
• Ability to think logically through clinical algorithms
• In primary care we also need to do this in a time-efficient way.

Perhaps the most crucial skill is the ability to listen to what the patient is saying.

This sounds simple, but it’s amazing how many people plough through history taking without really listening to the patient’s answers. This is inefficient, and can send you in the wrong diagnostic direction. It’s far more effective to assimilate the replies, as you go on, in order to start to narrow down the options.

The ability to listen and communicate well is not innate. Some of us are better at it than others, and we may have to work at it. Good communication begins with listening and observing, in order to understand how best to pitch our approach in terms of language, content and manner. Techniques such as mirroring posture and reflecting back comments may help show patients that you are focused on them and hearing their responses.

LEARNING TO TAKE A HISTORY: THE BUILDING BLOCKS

When we first learn history taking we use a series of structured questions. This is sometimes termed the hospital clerking model. (See box)

This approach is thorough, makes us certain we’ve missed nothing and extracts lots of data from the patient, but it is time consuming because it asks each patient a very full set of questions. This makes it harder to discard what’s not relevant as you go along, and it tends to concentrate the mind of the questioner on their questions, rather than on the answers. At worst it can mean that the doctor or nurse does all the talking. This may disengage the patient, who may wonder why they are being asked if they have ever passed a kidney stone when they are presenting with pneumonia.

Learning this basic method is essential in our training, as it is part of the basis from which we construct our focused history. Only when we have it committed to our memory can we then select from it the bits that matter. It also gives us a thorough set of questions to fall back on if none of our differential diagnoses seem to fit the symptoms.

ASKING QUESTIONS

Questions should be asked one at a time, and negative questions (e.g. you don’t get itchy with it, do you?) should be avoided: they are potentially confusing. They may alarm patients, or patients may agree with them without listening properly because they want to agree with you.

Reserve personal or intimate questions until rapport is established, and use appropriate warnings to signal to the patient that they are coming.

There are various types of question:

Open questions

Open questions are those that allow the patient to answer freely. They:

• Allow the patient to expand on symptoms
• Allow you a fuller understanding of their experience
• Mean that patients tend to talk more than the doctor/nurse
• Allow the patient to feel heard and to become a partner in their own consultation
• Help develop a patient-centred manner

Some examples of open questions are:

• Describe the pain to me?
• Tell me a bit more about the rash?
• How do you feel about all this?

Open questions are useful early in the consultation when you want to get maximum information from the patient and encourage them to talk. But they can use up time if patients are very talkative or raise multiple unrelated symptoms that confuse the picture

Doctors and nurses often talk about a golden minute (or even a golden two minutes) at the start of a consultation, when you let the patient explain their situation and try not to interrupt.

Closed questions

Closed questions are those that have a limited choice of answer. They:

• Limit the patient to short answers or even yes/no
• Allow you to drill down and get fast answers around symptoms that worry you (e.g. does the rash blanch when pressed?)
• Can be a time-efficient way of finding out specific facts that the patient may not rank as important enough to mention
• May increase the patient’s confidence in the doctor or nurse (as they demonstrate that you have heard the symptoms and are analysing them)
• Can mean the doctor or nurse is talking more than the patient
• Can make the consultation feel doctor/nurse-centred and the patient feel excluded, if used excessively/inappropriately

Closed questions are generally more useful later in the history taking when you are seeking to confirm your thoughts on diagnosis or to rule out red flags. Some examples are:

• When exactly did the pain start?
• Does the rash blanch when you press it?
• What time do you wake in the morning?

Probing questions

Probing questions lie somewhere between open and closed questions. They may follow up an open question to narrow down the responses, for example

• How does the pain affect your ability to manage your day?
• How does the bullying make you feel?
• What’s your sleep pattern been like this last week?

Probing questions help clarify the open answers and are time-efficient without shutting down the patient’s share of the discussion.

Open, closed and probing questions all have their uses and all are needed in good history taking. Generally open questions should predominate at the beginning of the consultation, when the patient should normally do most of the talking, and closed questions come to the fore as you begin to formulate your diagnosis and cross check it.

The proportion of time spent on the different types of question will vary with the consultation. You may need to move to closed questions very early if the diagnosis is very obvious, if red flag symptoms are revealed or if the presenting complaint may be life threatening. In these circumstances becoming very doctor/nurse-centred is often the most appropriate course.

ORGANISING THE PRIMARY CARE HISTORY

Prepare for the patient, if you have access to their notes. Even in a very rushed clinic, try to look at the last encounters with the surgery, any recent hospital letters and the clinical summary. Patients who attend regularly may be very upset if your initial questions suggest you know nothing about them.

1. The presenting complaint

The first part of the history should always be about establishing why the patient has come. This helps your thinking, makes sense to patients and helps them to put their story together clearly for you. Keep your questions very open. ‘What have you come to see me about?’ ‘Tell me more about that.’

Some people suggest avoiding, ‘What can I do for you today?’ on the basis that it raises expectations. The author has used this phrase for many years and has never found it to be a problem, and patients have felt it indicated an intent to help.

We refer to the reason for attendance as the ‘presenting complaint’ and the information about this the ‘history of the presenting complaint’:

• What is it?
• How long has it been a problem for?
• Is it getting better, getting worse or staying the same?
• What relieves it or makes it worse?
• If it’s pain, what’s it like? Where? When does it come on? Where does it spread to?
• How does it make you feel? How is it affecting you?
• What do you think it is? Is anything worrying you about it?

2. Background

Other information may then be helpful, depending on the circumstances. Working your way through the following areas, leaving out those that you feel are irrelevant to the problem, can be helpful. Consider:

• Past medical history (chronic conditions, conditions requiring medication and the most recent are usually, but not always the most relevant). Ask about major or important illnesses or operations
• Medication – including over-the-counter and herbal remedies – present and also past
• Family history – who is there, how are they? Any illnesses in the family?
• Social history – smoking, alcohol, drugs, life circumstances, who is there for your patient? Do they work?
• Systems review: there are specific questions for the cardiovascular, respiratory, abdominal, neurological, musculoskeletal and GU systems. Not all will be relevant or necessary in every consultation
• In children – immunisation and developmental history
• In women of childbearing age, obstetric and gynaecology history

3. What matters to the patient? Discovering the agenda

Understanding the patient’s perspective is crucial to patient satisfaction. The Disease-Illness model of consulting may be helpful.² It looks at your patient encounter as shows two parallel agendas.

For example, you see a patient with knee pain. Your agenda may be to rule out ligament injury by arranging imaging. The patient’s agenda may be to play in the football final on Saturday. Your basic goals are the same, to arrive at the correct diagnosis and to get the patient better, but the perspectives differs.

• The patient’s agenda involves their ideas, concerns and expectations, and is set in the context of their life and experience and emotional milieu.
• Your agenda involves wanting to be correct, do the right thing and achieve the right long-term outcome.

If you don’t make sure you’ve worked out the patient’s agenda they may leave the consultation with their main question unanswered.

It’s important in history taking to ask, early on, not only what the patient is experiencing but also what their perspective is. What are they concerned it might be? What has experience led them to conclude? What do they hope you can do today?

4. Focused and probing questions

Use the rest of the history to probe around the problem. By now you should be building a list of differential diagnoses and trying to work out which fits.

Closed questions may be useful. Rule out sinister and life threatening conditions. If you can’t rule them out then they remain possibilities, and even if they are less likely than your main diagnosis you must act on them.

5. Examination

This is a part of clinical data gathering and belongs with history taking – but the art of focusing your examination is important in primary care. This will be discussed in a future article.

Winding up

Once you have completed your history taking, consider summarising back to the patient. This can be as helpful to you as to them as it helps you gather your thoughts. So you might say, ‘so you’ve had the pain since Thursday, it comes and goes in waves, it’s getting steadily worse and you feel sick with it. You’ve not had any other symptoms and your bladder and bowels have been working normally. You think it might be related to the chicken you ate the night before. Is that all correct?’

By now you should have formulated a list of differential diagnoses, and hopefully there’s one that you think is more likely. It’s time to move on to communicating, to the patient, the list of possibilities, the one you think most likely (and why), and what you suggest they do next.

Summary

History taking is both a science and an art. Good history taking helps establish a communicating and helpful relationship with the patient, as well as providing the information we need in order to make a diagnosis, in a time efficient manner.

Good history taking needs knowledge, skill and experience. The practice nurse is well placed to become an expert in this area.

REFERENCES

1. The Osler Symposia http://www.oslersymposia.org/about-Sir-William-Osler.html

2. Stewart M et al. Patient-centred medicine: transforming the clinical method. Abingdon Oxford; Radcliffe Medical Press; 2003