Patient history: what you need to ask

Patient history: what you need to ask

One of the most important jobs you have as a nurse is communicating with your patients. In addition to finding out what’s happening now, you’ll need to arm yourself with accurate and detailed information about what’s happened previously, both recently and longer ago. Past illnesses and accidents may seem unrelated but could have a significant impact on your patient’s wellbeing, so here’s our checklist of those essential patient history questions you need to ask!

  1.  Get off to a good start by asking the patient how he or she would like to be addressed – the name they prefer might not be the name you see on their notes. They might feel more comfortable being referred to as ‘Mr’ or by a title, such as ‘Doctor’, than a Christian name, while the difference between Mrs, Ms and Miss does matter!
  2. When it comes to the immediate situation, remember the ‘w’s; why, what, where? Why are they seeking help? What happened? Where is the pain? Go through their symptoms carefully and ask if and how they have changed in the last few hours, days or weeks.
  3. Ask them about their medical history. Have the current symptoms happened before? This is a good chance to build up a detailed picture regarding past illnesses, accidents, hospitalisations and surgeries. Ask them about childhood illnesses, accidents and operations too.
  4. Find out about your patient’s background and family. Your questions should include asking about close relatives’ health, to find out if there are genetic conditions in the family. Bear in mind that some patients will be adopted, and it’s even possible that some won’t be aware of it.
  5. Do they have any allergies? Your notes should include food allergies as well as reactions to medication, such as penicillin.
  6. Find out whether the patients smokes, or used to. How many cigarettes a day does he or she have? When did they give up? Ask them also about whether they drink alcohol and, if so, how many units per week.
  7. Ask your patient about any substance use, past or present. Now might be a good time to find out what’s going on at home, too, in terms of who they live with and whether there are any problems.
  8. Other things to remember include avoiding the use of medical jargon or technical terms in your questioning. If the patient doesn’t understand the question, you’re unlikely to get a reflective answer. Use plain English and include a mixture of ‘closed’ and ‘open’ questions, to get the conversation flowing. Be friendly and smile a lot; if the subject is personal or difficult for the patient to think about, positive body language will help put them at their ease.
  9. Include relatives in your questioning. Parents will often remember small details that children won’t, while patients who are confused or in pain are likely to need prompts to answer fully.
  10. Double check your facts, such as giving a brief summary of your notes at the end and asking the patient to confirm it’s accurate. Remember there’s no such thing as a silly question, so never be afraid to ask, however obvious something seems, and never make an assumption – it could ultimately put your patient’s life at risk.

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