Taking a history

Taking a history

Nurses are traditionally people who do things to make people better, or at least more comfortable. However, the work is inefficient and sometimes even dangerous if they do not first gather the relevant information to tailor their actions to the individual patient or situation.1 This is just as true of practice nursing as any other form of nursing, and is still important even when you know the patient well. This module will explore content and methods of gathering a history and how to adapt those methods to suit the circumstances and the people involved.

This resource, consisting of five assessment questions at basic level, tests your knowledge of the skills required for taking a history. Complete the resource, including reading the featured articles and undertaking some or all of the activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

After completing this module you will know how to:

• Describe the components of a comprehensive history
• Distinguish key aspects of a patient’s history in specific circumstances
• Discuss methods of helping people to express what is important to them
• Document an accurate history with due attention to confidentiality and appropriate language

Reference

1. Hastings A & Redsell S (Eds) The Good Consultation Guide for Nurses. Radcliffe Publishing, Oxford. 2006