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A guide to taking a patient’s history

Article (PDF Available) in Nursing standard: official newspaper of the Royal College of Nursing 22(13):42-8 ·  December 2007with23,748 Reads

DOI: 10.7748/ns2007. · Source: PubMed

Hilary Lloyd
Hilary Lloyd

Stephen Craig at Northumbria University
Stephen Craig
  • 4.44
  • Northumbria University

This article outlines the process of taking a history from a patient, including preparing the environment, communication skills and the importance of order. The rationale for taking a comprehensive history is also explained.

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42 december 5 :: vol 22 no 13 :: 2007
TAKING A PATIENT history is arguably the most
important aspect of patient assessment, and is
increasingly being undertaken by nurses (Crumbie
2006). The procedure allows patients to present
their account of the problem and provides
essential information for the practitioner.
Nurses are continually expanding their roles,
and with this their assessment skills. It is likely
that history taking will be performed by a nurse
practitioner or specialist nurse, although it can
be adapted to most nursing assessments. The
history is only one part of patient assessment and is
likely to be undertaken in conjunction with other
information gathering techniques, such as the single
assessment process, and nursing assessment.
History taking for assessment of healthcare
needs is not new. Many nursing theorists have
examined health deficits (Henderson 1966, Roper
et al 1990, Orem 1995), all of which rely on careful
assessment of patients’ needs. Other nursing
theorists identified interaction theories (Peplau
1952, Orlando 1961, King 1981), which sought to
develop the relationship between the patient and
the nurse through systematic assessment of health.
This article provides the reader with a
framework in which to take a full and
comprehensive history from a patient.
Preparing the environment
The first part of any history-taking process and,
indeed, most interactions with patients is
preparation of the environment. Nurses can
encounter patients in a variety of environments:
accident and emergency; general wards;
department areas; primary care centres; health
centre clinics and the patient’s home. It is
important that the environment in practical terms
is accessible, appropriately equipped, free from
distractions and safe for the patient and the nurse
(Crouch and Meurier 2005).
Respect for the patient as an individual is an
important feature of assessment, and this includes
consideration of beliefs and values and the ability
to remain non-judgemental and professional
(Rogers 1951). Respect also involves maintenance
of privacy and dignity; the environment should be
private, quiet and ideally, there should be no
interruptions. When this is not possible the nurse
should do everything possible to ensure that
patient confidentiality is maintained (Crouch and
Meurier 2005).
It is essential to allow sufficient time to
complete the history. Not allowing enough time
can result in incomplete information, which may
adversely affect the patient’s care.
The importance of taking a comprehensive
history cannot be overestimated (Crumbie 2006).
The nurse should be able to gather information in
a systematic, sensitive and professional manner.
Good communication skills are essential.
Introducing yourself to the patient is the first part
of this process. It is important to let patients tell
their story in their own words while using active
listening skills. It is also important not to appear
rushed, as this may interfere with the patient’s
desire to disclose information (Hurley 2005).
Developing a rapport with the patient includes
being professionally friendly, showing interest
and actively using both non-verbal and verbal
communication skills (Mehrabian 1981) (Box 1).
Practitioners should avoid the use of technical
terms or jargon and, whenever possible, use the
patient’s own words.
A guide to taking a patient’s history
Lloyd H, Craig S (2007) A guide to taking a patient’s history. Nursing Standard. 22, 13, 42-48.
Date of acceptance: August 24 2007.
art & science clinical skills: 28
This article outlines the process of taking a history from a patient,
including preparing the environment, communication skills and the
importance of order. The rationale for taking a comprehensive
history is also explained.
Hilary Lloyd is principal lecturer in nursing practice, development
and research, City Hospitals Sunderland NHS Foundation Trust,
Sunderland, and Stephen Craig is senior lecturer in nursing,
Northumbria University, Newcastle upon Tyne.
Email: hilary[email protected]
Assessment; Communication; History taking
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at For related articles
visit our online archive and search using the keywords.
p42-48w13 29/11/07 11:52 am Page 42
Before any healthcare intervention, including
history taking, informed consent should be
gained from the patient. It can be obtained using
various methods. However, both the Nursing
and Midwifery Council’s (NMC 2004) Code of
Professional Conduct and the Department of
Health’s (DH 2001) Good Practice in Consent
Implementation Guide state that patients can
only provide consent if they are able to act
under their own free will, have an
understanding of what they have agreed to and
have enough information on which to base a
The ability of the patient to give consent to
history taking is important. Consent is governed
by two acts of parliament: the Mental Capacity
Act 2005 in England and Wales and the Adults
with Incapacity (Scotland) Act 2000 in Scotland.
There is currently no equivalent law on mental
capacity in Northern Ireland. In addition, each
health trust will have a local policy that the nurse
should follow. The NMC (2007a) and DH
(2007a) websites provide further information on
the Mental Capacity Act 2005 and consent.
The history-taking process
There are some general principles to follow when
gathering information from patients.
Introductions As stated earlier, always begin
with preparing the environment, introducing
yourself, stating your purpose and gaining
consent. Once this has been completed, it is best
to begin by establishing the identity of the patient
and how he or she would like to be addressed
(Hurley 2005). The first information to be
gathered as with any history is basic
demographic details, such as name, age and
Order and structure The general structure of
history taking follows the process outlined in
Box 2. There is a consensus in medical and
nursing texts that it is important to have a logical
and systematic approach (Douglas et al 2005,
Crumbie 2006). Many books and articles also
suggest that the history should be taken in a set
order (Douglas et al 2005, Shah 2005), however,
it is not necessary to adhere to these rigidly.
Open questions It is important to use appropriate
questioning techniques to ensure that nothing is
missed when taking a history from a patient.
Always start with open-ended questions and take
time to listen to the patient’s story. This can
provide a great deal of information, although not
necessarily in a systematic order. Examples of
open questioning include: ‘Tell me about your
health problems?’ and ‘How does this affect
Closed questions Once the patient has completed
his or her ‘story’ move on to clarify and focus
with specific questions. Closed questions provide
extra detail and sharpen the patient’s story.
Examples of closed questioning include: ‘When
did it begin?’ and ‘How long have you had it for?’
Clarification Clarification involves recalling
back to the patient your understanding of the
history, symptoms and remarks. Summarising
the history back to the patient is necessary to
check that you have got it right and to clarify any
discrepancies. Finally, asking the patient, ‘Is there
anything else?’ gives him or her a final
opportunity to add any further information.
In general, interviewing skills develop
through practice. Some helpful points of
guidance to consider include (Morton 1993):
Encouraging participation and agreement.
Offering prompts and general leads.
Focusing the discussion.
Placing symptoms or problems in sequence.
Using pauses effectively.
Making observations that encourage the
patient to discuss symptoms.
december 5 :: vol 22 no 13 :: 2007 43
Examples of non-verbal and verbal
communication skills
Non-verbal Verbal
Eye contact Appropriate language
Interested posture Avoid jargon and technical terms
Nodding of head Pitch
Hand gestures Rate and intonation
Clothing Volume
Facial gestures
(Mehrabian 1981)
History-taking sequence
The presenting complaint.
Past medical history.
Mental health.
Medication history.
Family history.
Social history.
Sexual history.
Occupational history.
Systemic enquiry.
Further information from a third party.
(Adapted from Douglas et al 2005)
p42-48w13 29/11/07 11:52 am Page 43
Clarifying points by restating points raised.
There are also some techniques that should be
avoided. These are outlined by Crumbie (2006)
(Box 3).
Calgary Cambridge framework
Kurtz et al (2003) refined the Calgary Cambridge
Observation Guide (CCOG) model of
consultation to include structuring the
consultation. The CCOG is useful as it facilitates
continued learning and refining of consultation
skills for the teacher and practitioner and is an
ideal model for both ‘novice’ and ‘experienced’
nurses. Kurtz et al (2003) suggested five stages to
summarise history taking including:
Explanation and planning Giving patients
information, checking that it is correct and that
you both agree with the history that has been taken.
Aiding accurate recall and understanding
Making information easier for the patient using
Achieving a shared understanding
Incorporating the patient’s perspective to
encourage an interaction rather than a one-way
Planning through shared decision making
Working with patients to assist understanding and
involving patients in the decision-making process.
Closing the consultation Explaining, checking
and offering a plan acceptable to the patient’s
needs and expectations.
Taking the history
If the structure advised by Douglas et al (2005) is
used, history taking should start with asking the
patient about the presenting complaint.
The presenting complaint To elicit information
about the presenting complaint start by using an
open question, for example: ‘What is the
problem?’ or ‘Tell me about the problem?’. This
should provide a breadth of valuable information
from the patient, but not necessarily in the order
that you would like. The patient should then be
asked more specific details about his or her
symptoms, starting with the most important first.
It is important to concentrate on symptoms and
not on diagnosis to ensure that no information is
missed. Most textbooks provide a list of cardinal
symptoms – those symptoms that are most
important to that body system – and should be
asked about to ensure that a full history is obtained
from the patient. Box 4 provides a list of examples
of the cardinal symptoms for each body system.
When a patient reports symptoms from a
specific body system, all of the cardinal
symptoms in the system should be explored.
For example, if a patient complains of
palpitations, then specific questions should be
asked about chest pain, breathlessness, ankle
swelling and pain in the lower legs when walking
to ensure that all cardinal questions relating to
the cardiovascular system have been covered.
Each symptom should be explored in more
detail for clarification because this helps to
construct a more accurate description of the
patient’s problems. Direct questions can be used
to ask about:
Onset – was it sudden, or has it developed
Duration – how long does it last, such as
minutes, days or weeks?
Site and radiation – where does it occur? Does
it occur anywhere else?
Aggravating and relieving features – is there
anything that makes it better or worse?
Associated symptoms – when this happens,
does anything else happen with it, such as
nausea, vomiting or headache?
Fluctuating – is it always the same?
Frequency – have you had it before?
Direct questioning can be used to ask about the
sequence of events, how things are currently and
any other symptoms that might be associated
with possible differential diagnoses and risk
factors. Negative responses are also important,
and it is vital to understand how the symptoms
affect the patient’s day-to-day activities.
44 december 5 :: vol 22 no 13 :: 2007
art & science clinical skills: 28
Examples of unhelpful interview techniques
Asking ‘why’ or ‘how’ questions.
Using probing persistent questions.
Using inappropriate or technical language.
Giving advice.
Giving false reassurance.
Changing the subject or interrupting.
Using stereotype responses.
Giving excessive approval or agreement.
Jumping to conclusions.
Using defensive responses.
Asking leading questions that suggest right answers.
Social chat: the person is expecting professional
(Crumbie 2006)
p42-48w13 29/11/07 11:52 am Page 44
Past medical history When a full account of the
presenting complaint has been ascertained,
information about the patient’s past medical
history should be gathered. This may provide
essential background information – for example,
on diabetes and hypertension, or a past history of
cancer. It is important to capture the following
information when taking a past medical history:
Begin by using questions such as, ‘What illnesses
have you had?’ Ensure that you have obtained a
full list of the patient’s past medical history and
explore each of these in detail as with the
presenting complaint. It is useful to prompt the
patient by using direct questioning to ask about
common major medical illnesses, such
as whether he or she has ever had tuberculosis;
rheumatic fever; heart disease; hypertension;
stroke; diabetes; asthma; chronic obstructive
pulmonary disease; or epilepsy.
Mental health According to the NHS
Confederation (2007), one in four people will
experience mental health problems at one time
during their life. This figure demonstrates that
nurses are likely to encounter mental health issues
frequently. By using skills previously highlighted,
and with a supportive and professional approach,
the nurse can enquire with confidence about the
patient’s current coping strategies, such as
anxieties over health problems (suspicion of
malignancy, impending surgery or test results) or
more developed mental health issues, such as
bipolar disorder or schizophrenia.
Further clues can be gained from the patient’s
prescribed medication history or previous
hospital admissions. The nurse may feel anxious
about enquiring about mental health issues, but
it is an important part of wellbeing and should be
Medication history This is crucially important
and should consider not only what medication
the patient is currently taking but also what he or
she might have been taking until recently.
Because of the availability of so many
medications without prescription, known as
over-the-counter drugs, remember to ask
specifically about any medications that have
been bought at the pharmacy or supermarket,
including homeopathic and herbal remedies. For
each medication ask about: the generic name, if
possible; dose; route of administration; and any
recent changes, such as increase or decrease in
dose or change in the amount of times the patient
takes the medication.
december 5 :: vol 22 no 13 :: 2007 45
Cardinal symptoms
General health
Weight change
Cardiovascular system
Chest pain
Ankle swelling
Pain in lower leg when walking
Central nervous system
Visual disturbance
Memory and concentration
Excessive thirst
Heat intolerance
Hair distribution
Change in appearance of eyes
Gastrointestinal system
Dental/gum problems
Difficulty in swallowing
Painful swallowing
Abdominal pain
Change in bowel habit
Colour of stools
Genitourinary system
Pain on urinating
Blood in urine
Risk assessment for sexually
transmitted infections
Hesitancy passing urine
Frequency of micturition
Poor urine flow
Urethral discharge
Erectile dysfunction
Change in libido
Joint pain
Joint stiffness
Time of day pain
Respiratory system
Shortness of breath
Blood in sputum
Pain when breathing
Onset of menstruation
Last menstrual period
Timing and regularity of
Length of periods
Type of flow
Vaginal discharge
Pain during
sexual intercourse
(Adapted from Douglas et al 2005)
p42-48w13 29/11/07 11:52 am Page 45
Concordance with medication is an important
part of taking a medication history. Finding out the
level of concordance and any reasons for non-
concordance can be of significance in the future
treatment of the patient. Finally, ask about any
allergies and sensitivities, especially drug allergies,
such as allergy or sensitivity to penicillin. It is
important to find out what the patient experienced,
how it presented in terms of symptoms, when it
occurred and whether it was diagnosed.
Family history Some disorders are considered
familial; a family history can reveal a strong
history of, for example, cerebrovascular disease
or a history of dementia, that might help to guide
the management of the patient. Open
questioning followed by closed questioning can
be used to gather information about any
significance in the patient’s family history. For
example, start with an open question such as:
‘Are there any illnesses in the family?’ Then ask
specifically about immediate family – namely
parents and siblings. For each individual ask
about diagnosis and age of onset and, if
appropriate, age and cause of death.
Social history A patient’s ability to cope with a
change in health depends on his or her social
wellbeing. A level of daily function should be
established throughout the history taking.
The nurse should be mindful of this level of
function and any transient or permanent change
in function as a result of past or current illness.
Questions about function should include the
ability to work or engage in leisure activities if
retired; perform household chores, such as
housework and shopping; perform personal
requirements, such as dressing, bathing and
cooking. In particular, with deteriorating health
a patient may have needed to give up club or
society memberships, which may lead to a sense
of isolation or loss.
Nurses should consider the whole of the
family when exploring a social history.
Relationships to the patient should be explored,
for example, is the patient married, is his or her
spouse healthy, do they have children and, if so,
what age are they? The health and residence to
the patient should be known to understand
actual and potential support networks. Other
support structures include asking about friends
and social networks, including any involvement
of social services or support from charities, such
as MIND (National Association for Mental
Health) or the Stroke Association.
The social history should also include enquiry
into the type of housing in which the patient lives.
This should include if the accommodation is
owned, rented or leased, what condition it is in
and whether there have been any adaptations.
Alcohol In relation to the social history ask
specifically about alcohol intake. The nurse
should ask about past and present patterns of
drinking alcohol. Ewing (1984) suggested use of
the CAGE system, in which four questions may
elicit a view of alcohol intake (Box 5). Hearne et
al (2002) considered it to be an efficient
screening tool.
The nurse should be wary of patients who are
evasive or indignant when asked questions about
alcohol consumption. A mental note should be
taken to ask again at a later stage and to consider
physical evidence of alcohol intake during the
physical examination. Many patients do not
recognise units of alcohol and will talk in
measures and volume for which the nurse will
have to have a mental ready reckoner to calculate
the weekly alcohol consumption. The DH
website provides useful guidance on this (Box 6).
46 december 5 :: vol 22 no 13 :: 2007
art & science clinical skills: 28
Equivalent units of alcohol
A pint of ordinary strength lager, for example,
Carling Black Label, Foster’s = 2 units.
A pint of strong lager, for example, Stella Artois,
Kronenbourg 1664 = 3 units.
A pint of ordinary bitter, for example, John Smiths,
Boddingtons = 2 units.
A pint of best bitter, for example, Fuller’s ESB,
Youngs Special = 3 units.
A pint of ordinary strength cider, for example,
Woodpecker = 2 units.
A pint of strong cider, for example, Dry Blackthorn,
Strongbow = 3 units.
A 175ml glass of red or white wine is around
2 units.
A pub measure of spirits = 1 unit.
An alcopop, for example, Smirnoff Ice, Bacardi
Breezer, WKD, Reef is around 1.5 units.
(DH 2007b)
The CAGE system
Have you ever felt the need to Cut down?
Have people Annoyed you by criticising your
Have you ever felt Guilty about your drinking?
Have you ever had a drink to steady your nerves in
the morning (Eye opener)?
(Ewing 1984)
p42-48w13 29/11/07 11:52 am Page 46
Nurses should be mindful that increased
alcohol consumption might be a reaction to the
health stressors affecting the patient during
adjustment to recent changes in health. It could
also be that the patient is drinking excessively to
act as both a physical and emotional analgesic.
Careful, but purposeful, questioning using a
mixture of the skills outlined should encourage
the nurse to have confidence to broach the topic
of alcohol dependence. Specific questioning
should include the quantity and type of alcohol
consumed and where the majority of the drinking
takes place, whether in isolation or company.
Smoking It is documented that smoking causes
early death in the population and no safe
maximum or minimum limit, unlike alcohol, has
been identified. Nurses should ask questions that
identify the history of the patient’s smoking.
Traditionally questions surrounding smoking
include: ‘What age did you start smoking?’,
‘What kind of cigarettes do you smoke?’, ‘How
many cigarettes a day do you smoke?’, ‘Do you
use roll ups or filtered?’ and ‘Are they low or high
tar content?’.
Patients will often be unclear about the
amount they smoke, but with persistence, ‘pack
years’ – now the standard measure of tobacco
consumption – can be calculated (Prignot 1987).
Pack years is a calculation to measure the amount
a person has smoked over a long period.
The pack year number is calculated by
multiplying the number of packs of cigarettes
smoked per day by the number of years the
person has smoked. For example, one pack year
is equal to smoking one pack per day for one year,
or two packs per day for half a year, and so on.
If an individual smokes three packs per day for
20 years then this would amount to 3 packs per
day x 20 years = 60 pack years.
Roll-up cigarettes are more difficult to
calculate as these are made by the patient and are
not a standard size. Tobacco is usually sold in
grams but verbalised in ounces. Approximate
tobacco amounts can be calculated (Box 7).
Illicit/recreational drugs In the British Crime
Survey, Roe and Man (2006) identified that just
under half (45.1%) of all 16-24-year-olds have
used one or more illicit drugs in their lifetime,
25.2% have used one or more illicit drugs in the
last year and 15.1% in the last month.
Recreational drugs are those that are used
regularly and which are a focus of a leisure
activity without interrupting the user’s abilities
and lifestyle (Vose 2000). Drug dependence
is when recreational use reaches a level of
‘tolerance’. This is the point where or when the
use of the drug requires larger more regular usage
to acquire the same initial effect.
Professional and appropriate behaviour by
the nurse, using careful and tactful questioning,
is needed to enable the patient to feel comfortable
in disclosing drug use. The nurse may uncover
unpleasant or illegal actions by the patient in
their pursuit of obtaining drugs or being under
the influence of drugs.
Sexual history This can be a difficult subject to
broach and it is not always appropriate to take a
full sexual history (Douglas et al 2005). Where
relevant ask questions in an objective manner,
but acknowledge the sensitivity of the subject by
starting with: ‘I hope you don’t mind but I need to
ask some questions about …’
In men, questions regarding sexual history can
be asked as part of the genitourinary system
history and should include any previous urinary
tract infections, sexually transmitted infections
and treatments provided. In women date of
menarche, regularity and character of periods,
pregnancies, live deliveries and terminations or
other losses should be recorded. Women should
also be sensitively asked about any infections and
treatments. High-risk sexual activity, such as
unprotected sexual intercourse should be
addressed in both genders. In men and women
an enquiry should be made regarding libido,
increased or diminished, to reflect both
psychological and endocrine systems.
Occupational history Taking a history should
include information on previous and current
employment. This is important as aspects of
employment other than the job itself can
influence social wellbeing if illness precludes a
return to work. For example, employment in
heavy industry may lead to respiratory
problems or joint problems. Although
occupations may date back several years,
exposure to some products may have a long
incubation period, such as resultant
mesothelioma after asbestos exposure.
Past and current employment will also
provide details of financial stability of the home.
Retired patients may have financial limitations,
as will patients who are currently unemployed.
Increased anxiety can be present in patients who
find themselves unable to work because of
sudden illness or having to care for a relative or
partner. Questions about a patient’s financial
condition should be unhurried and handled
sensitively by the nurse. This might include
discussion about social support and benefits
december 5 :: vol 22 no 13 :: 2007 47
Approximate calculation of tobacco
1 ounce = 28.34 grams
2 ounces = 56.69 grams
3 ounces = 85.04 grams
A ‘standard’ pouch of tobacco is equivalent to
50 grams
p42-48w13 29/11/07 11:52 am Page 47
because hospitalisation can alter the patient’s
eligibility for benefits.
Systemic enquiry The final part of history taking
involves performing a systemic enquiry. This
involves asking questions about the other body
systems not discussed in the presenting
complaint. The purpose of this is to check that no
information has been omitted. It involves
systematic questioning of symptoms relating to
cardiovascular, respiratory, gastrointestinal,
genitourinary, locomotor and dermatological
aspects and might yield important clues about
the cause of the presenting problems. The
cardinal symptoms for each system are outlined
in Box 4 and questioning should focus on the
presence or absence of these symptoms. It is
expected at this stage to receive a negative answer
to symptoms not already discussed. However, a
positive response to any of the questioning
should be investigated using the same method as
in the presenting complaint.
It is important not to overlook the value of
obtaining a collateral history from a friend or
relative. If necessary, and with the patient’s
permission, use the telephone to obtain this
information. It might be essential in a patient
presenting with an unexplained loss of
consciousness or cognitive symptoms.
Information from the history is essential in guiding
the treatment and management of a patient.
Alternatively, the prescribed medication history
may be checked with the GP practice if the patient
is not able to give a full history.
This article has presented a practical guide to
history taking using a systems approach. It
considered the key points required in taking a
comprehensive history from a patient, including
preparing the environment, communication
skills and the importance of order. While this
article provides the knowledge for taking a
history, the best method of achieving skills in
history taking is through a validated training
course with competency-based assessments.
The history-taking interview should be of a
high quality and must be accurately recorded
(Crumbie 2006). Nurses should be familiar with
the NMC Code of Professional Conduct
regarding competence, consent and
confidentiality (NMC 2004). The novice history
taker’s records should adhere to the NMC’s
(2007b) guidance on record keeping NS
48 december 5 :: vol 22 no 13 :: 2007
art & science clinical skills: 28
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2005/06 British Crime Survey in
England and Wales. The Stationery
Office, London.
Rogers CR (1951) Client Centred
Therapy: Its Current Practice,
Implications and Theory. Houghton
Mifflin. Boston MA.
Roper N, Logan WW, Tierney AJ
(1990) The Elements of Nursing: A
Model for Nursing Based on a
Model of Living. Second edition.
Churchill Livingstone, Edinburgh.
Shah N (2005) Taking a history:
introduction and the presenting
complaint. Student BMJ. 13,
September, 309-352.
Vose CP (2000) Drug abuse and
mental illness: psychiatry’s next
challenge! In Thompson T, Mathias
P (Eds) Lyttle’s Mental Health and
Disorder. Third edition. Baillière
Tindall and Royal College of
Nursing, London, 423-434.
p42-48w13 29/11/07 11:52 am Page 48

  • … Knowledge of the patient's presenting problem and individual health history is necessary to direct which body systems need to be assessed. Lloyd and Craig 2007 [22] Descriptive paper by two senior nursing lecturers in a peer review nursing journal. The article presents an argument why history taking should follow a structured approach, including details about the patient's presenting complaint and health history. …
    The development of HIRAID: an evidence-based emergency nursing assessment framework and education package
    Full-text available
    • Oct 2014
    • B. Munroe

      B. Munroe

    • K. Curtis

      K. Curtis

    • M. Murphy
    • L. Strachan
    • T. Buckley

      T. Buckley

  • … History taking forms an important part of patient assessment in nursing (Lloyd and Craig, 2007). This, through sound interviewing skills, allows nurses to identify priorities for care through clinical reasoning processes (Roberts, 2004) as well as identify where referral to other health professionals is required (Beck, 2007). …
    … This, through sound interviewing skills, allows nurses to identify priorities for care through clinical reasoning processes (Roberts, 2004) as well as identify where referral to other health professionals is required (Beck, 2007). A number of pieces of information are collected in comprehensive patient histories, including presenting condition/s, past medical history, family history, mental status, medication use (prescribed and non-prescribed), social and occupational history, reproductive history ( Lloyd and Craig, 2007). Cues received during history taking can then serve to direct physical examination (Kessenich, 2008), education or referral. …
    … Patient assessment is a complex process, and historically not a nursing role (Lloyd and Craig, 2007). However as nurses' roles have become increasingly sophisticated, assessment and decision making in such areas as pre-admission clinics, emergency departments, and nurse practitioner roles, patient assessment skills have become more vital (Kaufman, 2008). …
    Is history taking a dying skill? An exploration using a simulated learning environment
    • Dec 2010
    • Lisa McKenna

      Lisa McKenna

    • Kelli Innes

      Kelli Innes

    • Jill French
    • Sharyn Streitberg

      Sharyn Streitberg

    • Carole Gilmour

      Carole Gilmour

  • … Summarising gives the patient an opportunity to clarify details, make corrections and add further contributions (Moulton 2007). Asking the patient if there is anything else gives him or her a final opportunity to add any additional information (Lloyd and Craig 2007). When talking to patients it is easy to be side-tracked or omit important questions, therefore it is helpful to use a history-taking framework which gathers information in an orderly way. …
    Patient assessment: effective consultation and history taking
    Full-text available
    • Oct 2008
    • Nurs Stand
    • Gerri Kaufman

      Gerri Kaufman

  • An Overview to Clinical Diagnosis
    • Mar 2011
    • Phil Jevon

  • The effect of a scenario-based communications course on self-confidence in novice nurse communications
    • Oct 2011
    • Yu-Chun Huang
    • Li-Ling Hsu

      Li-Ling Hsu

    • Suh-Ing Hsieh

      Suh-Ing Hsieh

  • Systematically assessing chest pain in cardiac patients
    • Feb 2014
    • Mohammed Abdullah Al-Maqbali

      Mohammed Abdullah Al-Maqbali

  • HIRAID: An evidence-informed emergency nursing assessment framework
    • Apr 2015
    • Australas Emerg Nurs J
    • Belinda Munroe

      Belinda Munroe

    • Kate Curtis

      Kate Curtis

    • Margaret Murphy
    • Luke Strachan
    • Thomas Buckley

      Thomas Buckley

  • Taking a comprehensive health history: Learning through practice and reflection
    • Oct 2017
    • Br J Nurs
    • Shirley Ingram

      Shirley Ingram

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          Review of systems

          From Wikipedia, the free encyclopedia

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          A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). Along with the physical examination , it can be particularly useful in identifying conditions that do not have precise diagnostic tests. [1]

          Examples[ edit ]

          Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. Different sources describe slightly different systems of organizing the organ systems. However, the following are examples of what can be included:

          There are 14 systems recognized by the Centers for Medicare and Medicaid Services : [2]

          Constitutional symptomsunexplained weight loss , night sweats , fatigue / malaise / lethargy , sleeping pattern , appetite , fever , itch / rash , recent trauma , lumps /bumps/ masses , unexplained falls
          Eyes visual changes , headache , eye pain, double vision , scotomas (blind spots), floaters or “feeling like a curtain got pulled down” ( retinal hemorrhage vs amaurosis fugax )
          Ears, nose, mouth, and throat (ENT)Runny nose, frequent nose bleeds ( epistaxis ), sinus pain , stuffy ears, ear pain, ringing in ears ( tinnitus ), gingival bleeding , toothache , sore throat , pain with swallowing ( odynophagia )
          Cardiovascular chest pain , shortness of breath , exercise intolerance , PND , orthopnoea , oedema , palpitations , faintness , loss of consciousness , claudication
          Respiratory cough , sputum , wheeze , haemoptysis , shortness of breath , exercise intolerance
          Gastrointestinal abdominal pain , unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion , bloating , cramping , anorexia , food avoidance, nausea / vomiting , diarrhea / constipation , inability to pass gas ( obstipation ), vomiting blood ( haematemesis ), bright red blood per rectum (BRBPR, hematochezia ), foul smelling dark black tarry stools ( melaena ), dry heaves of the bowels ( tenesmus )
          Genitourinary Urinary : Irritative vs Obstructive symptoms: Micturition – incontinence , dysuria , haematuria , nocturia , polyuria , hesitancy , terminal dribbling , decreased force of stream
          Genital : Vaginal – discharge, pain, Menses – frequency, regularity, heavy or light (ask about excessive use of pads/ tampons , staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus , menarche , menopause , contraception (if relevant), date of last smear test and result
          Musculoskeletal pain , misalignment, stiffness (morning vs day long; improves/worsens with activity), joint swelling, decreased range of motion , crepitus , functional deficit , arthritis
          Integumentary /Breast pruritus , rashes , stria , lesions , wounds , incisions , acanthosis nigricans , nodules , tumors , eczema , excessive dryness and/or discoloration. Breast pain, soreness, lumps, or discharge.
          Neurological Special senses – any changes in sight , smell , hearing and taste , seizures , faints , fits , funny turns, headache , pins and needles ( paraesthesiae ) or numbness , limb weakness , poor balance , speech problems , sphincter disturbance , higher mental function and psychiatric symptoms
          Psychiatric depression , sleep patterns , anxiety , difficulty concentrating , body image , work and school performance, paranoia , anhedonia , lack of energy , episodes of mania , episodic change in personality , expansive personality , sexual or financial binges
          Endocrine Hyperthyroid : prefer cold weather, mood swings , sweaty , diarrhoea , oligomenorrhoea , weight loss despite increased appetite , tremor , palpitations , visual disturbances ;
          Hypothyroid – prefer hot weather, slow, tired , depressed , thin hair , croaky voice, heavy periods , constipation , dry skin
          Diabetes : polydipsia , polyuria, polyphagia (constant hunger without weight gain is more typical for a type I diabetic than type II), symptoms of hypoglycemia such as dizziness, sweating, headache,hunger, tongue dysarticulation
          Adrenal : difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed places
          Reproductive (female): menarche, cycle duration and frequency, vaginal bleeding irregularities, use of birth control pills, changes in sexual arousal or libido
          Reproductive (male): difficulty with erection or sexual arousal, depression, lack of stamina/energy
          Hematologic / lymphatic anemia , purpura , petechia , results from routine hemolytic diseases screening, prolonged or excessive bleeding after dental extraction / injury, use of anticoagulant and antiplatelet drugs (including aspirin ), family history of hemophilia, history of a blood transfusion, refused for blood donation
          Allergic / immunologic“Difficulty breathing” or “choking” ( anaphylaxis ) as a result of exposure to anything (and state what; e.g. “bee sting”). Swelling or pain at groin (s), axilla (e) or neck (swollen lymph nodes / glands ), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.

          The questions may be asked of the patient in a “head to toe” manner. [3]

          Relationship to history[ edit ]

          CMS required history elements [4]
          Type of history CC HPI ROS Past , family , and/or social
          Problem focusedRequiredBriefN/AN/A
          Expanded problem focusedRequiredBriefProblem pertinentN/A

          For CMS , a “problem pertinent” ROS is limited to the problem(s) identified in the HPI; an “extended” ROS covers an additional 2 to 9 systems, and a “complete” ROS covers at least 10 additional systems. [4]

          References[ edit ]

          1. ^ Tuite PJ, Krawczewski K (April 2007). “Parkinsonism: a review-of-systems approach to diagnosis” . Semin Neurol. 27 (2): 113–22. doi : 10.1055/s-2007-971174 . PMID   17390256 . 
          2. ^ “” (PDF). Archived from the original (PDF) on 2011-03-22. Retrieved 2011-02-27. 
          3. ^ Lynn S. Bickley; Peter G. Szilagyi (1 December 2008). Bates’ guide to physical examination and history taking . Lippincott Williams & Wilkins. pp. 10–. ISBN   978-0-7817-8058-2 . Retrieved 27 February 2011. 
          4. ^ a b “Evaluation and Management Services Guide” (PDF). December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27. 
          • v
          • t
          • e
          Medical examination and history taking
          Medical history
          • Chief complaint
          • History of the present illness
          • Systems review
          • Nursing assessment
          • Allergies
            • Medications
          • Past medical history
          • Family history
          • Social history
          • Psychiatric history
          • Progress notes
          • Mnemonics
            • SAMPLE
            • OPQRST
            • SOAP
            • COASTMAP
          Physical examination
          General/ IPPA
          • Inspection
          • Auscultation
          • Palpation
          • Percussion
          Vital signs
          • Temperature
          • Heart rate
          • Blood pressure
          • Respiratory rate
          • Oral mucosa
          • TM
          • Eyes ( Ophthalmoscopy , Swinging-flashlight test )
          • Hearing ( Weber , Rinne )
          • Respiratory sounds
          • Cyanosis
          • Clubbing
          • Precordial examination
          • Peripheral vascular examination
          • Heart sounds
          • Other
            • Jugular venous pressure
            • Abdominojugular test
            • Carotid bruit
            • Ankle-brachial pressure index
          • Liver span
          • Rectal
          • Murphy’s sign
          • Bowel sounds
          • Murphy’s punch sign
          Extremities / Joint
          • Back ( Straight leg raise )
          • Knee ( McMurray test )
          • Hip
          • Wrist ( Tinel sign , Phalen maneuver )
          • Shoulder ( Adson’s sign )
          • GALS screen
          • Mental state
            • Mini–mental state examination
          • Cranial nerve examination
          • Upper limb neurological examination
          • Apgar score
          • Ballard Maturational Assessment
          • Well-woman examination
          • Vaginal examination
          • Breast examination
          • Cervical motion tenderness
          Assessment and plan
          • Medical diagnosis
          • Differential diagnosis
          • v
          • t
          • e
          Symptoms and signs : general / constitutional ( R50–R61 , 780.6–780.9 )
          • Fever
            • Fever of unknown origin
            • Drug-induced fever
            • Postoperative fever
          • Hyperhidrosis
            • e.g., Sleep hyperhidrosis ; “sweating”
          • Hyperpyrexia
          • Hyperthermia
          • Chills
          • Hypothermia
          Aches/ pains
          • Headache
          • Chronic pain
          • Cancer pain
          • Myalgia
          Malaise and fatigue
          • Atrophy
            • e.g., Muscular atrophy
          • Debility (or asthenia )
          • Lassitude
          • Lethargy
          • Muscle tremors
          • Tenderness
          • Flu-like symptoms
          • v
          • t
          • e
          Symptoms and signs : cognition , perception , emotional state and behaviour ( R40–R46 , 780.0–780.5, 781.1 )
          Alteration of
          • Confusion ( Delirium )
          • Somnolence
          • Obtundation
          • Stupor
          • Unconsciousness
            • Syncope
            • Coma
            • Persistent vegetative state
          Fainting / Syncope
          • Carotid sinus syncope
          • Heat syncope
          • Vasovagal episode
          • Amnesia
            • Anterograde amnesia
            • Retrograde amnesia
          • Dizziness
            • Vertigo
            • Presyncope / Lightheadedness
            • Disequilibrium
          • Convulsion
          Emotional state
          • Anxiety
          • Irritability
          • Hostility
          • Suicidal ideation
          • Verbosity
          • Russell’s sign
          Perception /
          • Audition
          • Olfaction  : Anosmia
          • Hyposmia
          • Dysosmia
          • Parosmia
          • Phantosmia
          • Hyperosmia
          • Tactile perception
          • Taste : Ageusia
          • Hypogeusia
          • Dysgeusia
          • Parageusia
          • Hypergeusia
          • Visual perception
          • Hallucination : Auditory hallucination
          • v
          • t
          • e
          Symptoms and signs relating to the cardiovascular system ( R00–R03 , 785 )
          Chest pain
          • Referred pain
          • Angina
          • Aerophagia
          • Heart sounds
            • Split S2
            • S3
            • S4
            • Gallop rhythm
          • Heart murmur
            • Systolic
            • Diastolic
            • Continuous
          • Pericardial friction rub
          • Heart click
          • Bruit
            • carotid
          • Tachycardia
          • Bradycardia
          • Pulsus tardus et parvus
          • Pulsus paradoxus
          • doubled
            • Pulsus bisferiens
            • Dicrotic pulse
            • Pulsus bigeminus
          • Pulsus alternans
          • Pulse deficit
          Vascular disease
          • Gangrene
          • Palpitations
            • Apex beat
          • Cœur en sabot
          • Jugular venous pressure
            • Cannon A waves
          • Hyperaemia
          • Cardiogenic
          • Hypovolemic
          • Distributive
            • Septic
            • Neurogenic
          • v
          • t
          • e
          Symptoms and signs relating to the respiratory system ( R04–R07 , 786 )
          Medical examination and history taking
          • Stethoscope
          • Respiratory sounds
            • Stridor
            • Wheeze
            • Crackles
            • Rhonchi
            • Stertor
            • Squawk
            • Pleural friction rub
            • Fremitus
            • Bronchophony
            • Terminal secretions
          • Elicited findings
            • Percussion
            • Pectoriloquy
            • Whispered pectoriloquy
            • Egophony
          • Apnea
            • Prematurity
          • Dyspnea
          • Hyperventilation
          • Hypoventilation
          • Hyperpnea
          • Tachypnea
          • Hypopnea
          • Bradypnea
          • Agonal respiration
          • Biot’s respiration
          • Cheyne–Stokes respiration
          • Kussmaul breathing
          • Ataxic respiration
          • Respiratory distress
          • Respiratory arrest
          • Orthopnea / Platypnea
          • Trepopnea
          • Aerophagia
          • Asphyxia
          • Breath holding
          • Mouth breathing
          • Snoring
          • Chest pain
            • In children
            • Precordial catch syndrome
            • Pleurisy
          • Nail clubbing
          • Cyanosis
          • Cough
          • Sputum
          • Hemoptysis
          • Epistaxis
          • Silhouette sign
          • Post-nasal drip
          • Hiccup
          • COPD
            • Hoover’s sign
          • asthma
            • Curschmann’s spirals
            • Charcot–Leyden crystals
          • chronic bronchitis
            • Reid index
          • sarcoidosis
            • Kveim test
          • pulmonary embolism
            • Hampton hump
            • Westermark sign
          • pulmonary edema
            • Kerley lines
          • Hamman’s sign
          • Golden S sign
          • v
          • t
          • e
          Symptoms and signs : Speech and voice / Symptoms involving head and neck ( R47–R49 , 784 )
          • Acute aphasias
            • Expressive aphasia
            • Receptive aphasia
            • Conduction aphasia
            • Anomic aphasia
            • Global aphasia
            • Transcortical sensory aphasia
            • Transcortical motor aphasia
            • Mixed transcortical aphasia
          • Progressive Aphasias
            • Progressive nonfluent aphasia
            • Semantic dementia
            • Logopenic progressive aphasia
          • Speech disturbances
            • Speech disorder
            • Developmental verbal dyspraxia /‎ Apraxia of speech
            • Auditory verbal agnosia
            • Dysarthria
            • Schizophasia
            • Aprosodia / Dysprosody
            • Specific language impairment
            • Thought disorder
            • Pressure of speech
            • Derailment
            • Clanging
            • Circumstantiality
          Communication disorders
          • Developmental dyslexia / Alexia
          • Agnosia
            • Astereognosis
            • Prosopagnosia
            • Visual agnosia
          • Gerstmann syndrome
          • Developmental coordination disorder / Apraxia
            • Ideomotor apraxia
          • Dyscalculia / Acalculia
          • Agraphia
          Voice disturbances
          • Dysphonia / Aphonia
          • Bogart–Bacall syndrome
          • Post-nasal drip
          • Epistaxis
          • Orofacial pain
            • Toothache
            • Galvanic pain
            • Barodontalgia
          • Fremitus
          • Tooth mobility
          • Bruxism
          • Trismus
          • Ageusia
          • Hypogeusia
          • Dysgeusia
          • Parageusia
          • Hypergeusia
          • Xerostomia
          • Halitosis
          • Drooling
          • Hypersalivation
          • Neck mass
            • Cervical lymphadenopathy
          • Headache
          • Auditory processing disorder
          • Otalgia
          • Velopharyngeal inadequacy
          • Velopharyngeal insufficiency
          • Hypersensitive gag reflex
          • Jaw claudication
          • Hypomimia
          • v
          • t
          • e
          Symptoms and signs : digestive system and abdomen ( R10–R19 , 787,789 )
          • Nausea
          • Vomiting
          • Heartburn
          • Aerophagia
          • Dysphagia
            • oropharyngeal
            • esophageal
          • Odynophagia
          • Halitosis
          • Xerostomia
          • Hypersalivation
          • Burping
            • Wet burp
          • Flatulence
          • Fecal incontinence
            • Encopresis
          • Blood : Fecal occult blood
          • Rectal tenesmus
          • Constipation
          • Obstructed defecation
          • Diarrhea
          • Rectal discharge
          • Psoas sign
          • Obturator sign
          • Rovsing’s sign
          • Hamburger sign
          • Heel tap sign
          • Aure-Rozanova’s sign
          • Dunphy sign
          • Alder’s sign
          • Lockwood’s sign
          • Rosenstein’s sign
          • Abdominal pain
            • Acute abdomen
            • Colic
            • Baby colic
            • Abdominal guarding
            • Rebound tenderness
          • Abdominal distension
            • Bloating
            • Ascites
            • Tympanites
            • Shifting dullness
            • Bulging flanks
            • Fluid wave test
          • Abdominal mass
          • Hepatosplenomegaly
            • Hepatomegaly
            • Splenomegaly
          • Jaundice
          • Mallet-Guy sign
          • Puddle sign
          • v
          • t
          • e
          Symptoms and signs : skin and subcutaneous tissue ( R20–R23 , 782 )
          Disturbances of
          skin sensation
          • Hypoesthesia
          • Paresthesia
            • Formication
          • Hyperesthesia
          • Hypoalgesia
          • Hyperalgesia
          • Cyanosis
          • Pallor / Livedo
            • Livedo reticularis
          • Flushing
          • Petechia
          • Peripheral edema
          • Anasarca
          • Rash
          • Desquamation
          • Induration
          • Diaphoresis
          • Mass
            • Neck mass
          • Asboe-Hansen sign
          • Auspitz’s sign
          • Borsari’s sign
          • Braverman’s sign
          • Crowe sign
          • Dennie–Morgan fold
          • Darier’s sign
          • Fitzpatrick’s sign
          • Florid cutaneous papillomatosis
          • Gottron’s sign
          • Hutchinson’s sign
          • Janeway lesion
          • Kerr’s sign
          • Koebner’s phenomenon
          • Koplik’s spots
          • Leser-Trelat sign
          • Nikolsky’s sign
          • Pastia’s sign
          • Russell’s sign
          • Wickham striae
          • Wolf’s isotopic response
          • Aldrich-Mees’ lines
          • Beau’s lines
          • Muehrcke’s lines
          • Terry’s nails
          • v
          • t
          • e
          Symptoms and signs : nervous and musculoskeletal systems ( R25–R29 , 781.0, 781.2–9 )
          Primarily nervous system
          Primarily CNS
          Movement disorders
          • Dyskinesia : Athetosis
          • Tremor
          Gait abnormality
          • Scissor gait
          • Cerebellar ataxia
          • Festinating gait
          • Marche a petit pas
          • Propulsive gait
          • Stomping gait
          • Spastic gait
          • Magnetic gait
          Lack of coordination
          • Dyskinesia : Ataxia
            • Cerebellar ataxia / Dysmetria
            • Sensory ataxia
            • Dyssynergia
          • Dysdiadochokinesia
          • Asterixis
          • Abnormal posturing : Opisthotonus
          • Sensory processing disorder : Hemispatial neglect
          • Facial weakness
          • Hyperreflexia
          • Pronator drift
          Primarily PNS
          Gait abnormality
          • Steppage gait
          • Antalgic gait
          Primarily muscular
          Movement disorders
          • Spasm
            • Trismus
          • Fasciculation
          • Fibrillation
          • Myokymia
          • Cramp
          Gait abnormality
          • Myopathic gait
          • Trendelenburg gait
          • Pigeon gait
          • Tetany
          • Meningism
          Primarily skeletal
          • Rachitic rosary
          • Clubbing
          Primarily joint
          • Joint locking
          • v
          • t
          • e
          Symptoms and signs : urinary system ( R30–R39 , 788 )
          • Renal colic
          • Costovertebral angle tenderness
          • Dysuria
          • Vesical tenesmus
          • Urinary incontinence
            • Enuresis
            • Diurnal enuresis
            • Giggling
            • Nocturnal enuresis
            • Post-void dribbling
            • Stress
            • Urge
            • Overflow
          • Urinary retention
          • Oliguria
          • Anuria
          • Polyuria
          • Lower urinary tract symptoms
            • Nocturia
            • Urinary urgency
            • Urinary frequency
          • Extravasation of urine
          • Extrarenal uremia
          • Urinoma
          • Addis count
          • Brewer infarcts
          • Lloyd’s sign

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          • Medical terminology

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