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Health History Interview Assignment Sample

RN/DREXEL Home Study Program
CE CENTER

CE credit is no longer available for this article. Expired July 2005


Originally posted January 2004

A practical guide to a thorough history

SALLY BEATTIE DULAK, RN, MS, CNS, GNP

SALLY BEATTIE DULAK, a member of the RN editorial board, is an advanced practice nurse and consultant in cardiovascular disease in Columbia, Mo.

KEY WORDS: health history, chief complaint, alternative therapies, lifestyle. substance abuse

Obtaining a thorough history during an initial meeting with a patient is vital since this information is used to guide future medical and nursing care decisions. This review of the essentials will help you get the most out of your next nursing history.

It's more than a completed checklist or form in a patient's chart. An accurate and complete health history is the first step in patient assessment that not only provides essential medical information, but serves as the foundation of future interactions with your patient.

For you, the nurse, obtaining a health history is a conversation with a purpose, a structured interview.1 Besides using it to gather information, this interview can help you to establish a trusting and supportive relationship with your patient. A thorough history also provides insight into the patient's social, emotional, cultural, and spiritual identity. In addition, it helps identify areas of strength, as well as any needs the patient may have in maintaining good health and coping with disease.2

Whether you're a recent graduate or an experienced nurse, keeping your history-taking skills sharp is critical. This review should help, with a review of not only the basics, but some of the finer points that can help you to further hone your skills.

It all begins with a proper introduction

Before you begin, do whatever you can to provide a comfortable, quiet, and private setting for the interview. Sit facing the patient at eye level. Address the patient formally when introducing yourself and use your full name and title. Doing this helps convey feelings of respect for the patient and for the information that she is about to share with you. You should explain the purpose of the health history and reassure the patient that this information is part of her medical record and will therefore be kept confidential.

To help put your patient at ease, maintain a calm, non-judgmental attitude throughout the interview. Appearing hurried and impatient or reacting to responses with disapproval, embarrassment, or condescension will block communication and hinder the establishment of a trusting, caring relationship.1

Although the actual history form you'll use will vary depending on the institution and clinical setting, every health history has six basic components: biographical data, a description of the patient's chief complaint, history of the present illness or problem, a review of the patient's overall health history, the family health history, and data related to the patient's lifestyle and social history.

The first set of questions usually focuses on biographical data: name, address, date and place of birth, marital status, occupation, type of healthcare insurance, and next of kin or emergency contact.1,3 In many situations this part of the history form is completed by a medical assistant or admitting clerk before your interview. When that's the case, you'll still want to review this information before beginning the interview since this data serves, in a way, as your introduction to who the patient is. Responses concerning the patient's occupation, insurance, and emergency contacts can be your first clues to important points you'll need to consider later during discharge planning.

Likewise, if previous records are available, they too should be reviewed so that you're aware of any ongoing health problems or concerns. Having this information at the start of the interview demonstrates an interest in the patient and will save time when you discuss the patient's medical history.

The chief complaint in the patient's words

After you've reviewed the biographical data, you are ready to focus on why the patient is here now. Begin with an open-ended question: What caused you to come in today? or What concerns made you feel you needed to be seen?

Allow the patient to tell the story. Even if you are aware of the reason for a patient's visit—admission to the hospital for surgery, for example—it's important to ask this question so you can get a sense of the patient's understanding of the problem.

Record the chief complaint as a direct quote: "My stomach has been hurting for three days and I can't eat." "I got dizzy and fell down while getting supper ready last night."1-3

Once you've established why the patient is seeking care, focus on the history of the present illness. This will give you a clear chronological account of the chief complaint and the circumstances surrounding its onset. Establishing an accurate sequence and time frame is critical for facilitating the development of the medical and nursing diagnoses and a plan of care.

Pay close attention to what the patient is telling you and ask for clarification as needed. Ask one question at a time and wait for the patient to completely answer the question before moving on.1

Begin by asking when and where the problem first started. Ask how the patient felt prior to the symptom's onset. When you being to explore the reason the patient is seeking care, make a conscious effort to use common phrases and terms that are easy to understand. Medical terminology or jargon could confuse the patient or provoke anxiety.1-3 For example, if the patient says she came to the clinic because of chest pain, be sure to ask if the pain moves or spreads to any other parts of the body rather than asking if it radiates.

To obtain a complete history of the present illness you'll need to cover these 10 characteristics:

1 Location:Where does the symptom occur? If the patient's answer is vague, ask her to point to the exact spot. That can help you get a more specific answer.

2 Radiation: Is the symptom confined to one area or does it spread? Again, it's helpful to ask the patient to point to, or indicate, the areas.

3 Quality:What does the dis- comfort feel like? If the patient has difficulty giving you this information offer some suggestions. Is it a throbbing, aching, or burning sensation? Is it sharp or dull? Does the quality change with time? For example, does a sharp sensation become dull? Does a tingling or throbbing sensation progress to numbness?

4 Quantity:This characteristic is very subjective. Therefore, having the patient rate the severity of the symptom using a scale of 0 – 10, with 10 being the most severe, may be more helpful than asking how bad the symptom makes her feel.

Asking the patient to describe the symptom in relation to its effects on daily activities may also give you more helpful specifics. For example, if the patient says she feels short of breath, ask her if this prevents her from walking up a flight of stairs or talking on the phone for more than five minutes. Tailor your questions to get as much specific information as possible.

5 Timing: This characteristic has three elements: onset, duration, and frequency.1 Here again, you want to use questions that will give you as many specifics as possible. When does the problem occur? Is it only in the morning when the patient first awakens? Does it occur just before or after a meal or after exercise? Once it starts, does it last just a few minutes or does it continue for several hours or even days? How many minutes or hours exactly? Does it seem to subside and then get worse? How many times has the symptom occurred in the last month?2

6 Associated manifestations:These are signs and symptoms associated with the chief complaint. For example, if the patient is complaining of a severe headache, does she also experience nausea, dizziness, or blurred vision? Does the patient experiencing abdominal pain after eating, have any nausea, or change in bowel habits?

Be sure to note both positive and negative findings. Depending upon the nature of the presenting problem, both can be equally important in making an accurate diagnosis.

7 Aggravating factors: What circumstances make the problem worse? These factors may be physical such as a change in the weather, exposure to allergens, changes in diet, specific types of physical activity, or a change in body position. Behavioral changes such as increased emotional stress or lack of sleep can also be contributing factors.

8 Alleviating factors:What does the patient do to feel better? If the patient has sought help for this problem before, what was the recommended treatment? Was it successful or is she seeking care now because previously prescribed therapy is no longer working?

9 Setting:Where was the patient and what was she was doing when she first noticed the symptom? This information can often provide valuable clues to precipitating factors related to the onset and course of the present illness. For example, after answering these questions a patient may realize that her dull headaches started the day the painters started work in her home.

10 Significance: Conclude this part of the interview with a discussion about the effect of this illness on her lifestyle and its significance. Having this information will help you to identify the patient's need for more support, education, or additional services at discharge.

For example, when asked about the effect of her problem on activities of daily living, an older patient with a complaint of minor knee pain may tell you that the pain makes it difficult for her to do her errands or housework. Or the patient may tell you she's very concerned about her recurrent indigestion because a friend who had the same symptoms just died from liver cancer.

When you've finished, briefly summarize what the patient has told you and give the patient the opportunity to make any necessary corrections or additions.3

Be sure to ask about past health concerns

In the next phase of the interview, your questions will focus on the patient's overall health history. Review the previous records of an established patient and make any appropriate updates concerning the continued treatment or resolution of other health problems. Be sure to ask about any injuries or surgeries that may have occurred since the last visit. If this is the patient's first visit you'll need to go into more detail.

Ask about past and chronic health problems. Questions like: When did you last see a doctor? or How often have you seen a doctor in the last year? are a good way to start. At this point it's very important to remember that people's perceptions and responses to health issues are very different and are influenced by a number of factors.

For example, the patient may tell you she used to see a doctor every year for heart trouble and high blood pressure but she stopped going two years ago because it was too hard to get an appointment because of her work schedule.

If the patient is currently being treated for another condition, find out the name of the physician and the type of therapy prescribed. Note the date and type of any surgery and ask the patient if there were any related complications or problems with anesthesia.

Ask too about any health problems the patient has treated and resolved with over-the-counter or home remedies. Have there been any problems or conditions that have simply gone away on their own? Has the patient explored alternative therapies such as acupuncture, massage therapy, or homeopathy?

Next find out what medications the patient is currently using. In addition to prescription drugs, be sure to ask about all creams, lotions, sprays, and over-the-counter preparations like laxatives, sleep aids, and analgesics. Also ask about any vitamins, herbs, or dietary supplements. Record the dosage and frequency for each preparation.

Inquire if the patient has recently stopped or restarted a medication, and if so, why. Does the patient ever use medications prescribed for another family member or friend? If so, what is it and how often does the patient do this?

Is the patient allergic to any medications, foods, animals, insects, latex, or other substances? When the answer is Yes, find out exactly what happens with exposure. Sometimes, what a patient considers an allergy—diarrhea or an upset stomach while taking an antibiotic—may be just an unpleasant side effect.

On the other hand, if the patient reports a severe or life-threatening reaction such as trouble breathing, heart palpitations, or hives, find out what treatment was used to stop the reaction. Does this patient wear a medical alert bracelet or carry emergency medication like epinephrine?

To complete this section, inquire about communicable diseases and immunizations. Did the patient have any communicable diseases such as mumps, chicken pox, diphtheria, rheumatic or scarlet fever, measles, or polio as a child? At what age did it occur and were there any complications?

Because of the social stigma attached to many of the adult communicable diseases, use sensitivity and professional judgment when asking questions about exposure to and treatment for HIV, herpes, hepatitis, and other sexually transmitted diseases.

For example, you may want to start by asking if the patient has ever been treated for a sexually transmitted disease like syphilis or herpes in the past and then find out if she's still sexually active. If she has been sexually inactive for the last 30 years, approach the issue of HIV exposure by asking if she's ever had a blood transfusion.

Inquire about travel to foreign countries and exposure to other communicable diseases like tuberculosis. Also ask about any immunizations required for travel. Does the patient get a pneumonia or flu shot in the winter? When did she receive her last tetanus booster? Has she been vaccinated against hepatitis?

Next, ask about the family's health history. Reviewing the patient's family history can provide you with important clues to the patient's risk for many diseases.3 To avoid any misunderstanding, mention this fact to the patient before you start asking questions about the health of her parents, siblings, and children.

Ideally, you'll want to know the age and health status of each living relative and the age and cause of death for any who are deceased. You're looking for any history of heart disease, stroke, hypertension, diabetes, cancer, hypercholesterolemia, depression, alcoholism, epilepsy, asthma, or kidney disorders.

Since family relationships can be complicated, do not press the patient if she's unable or unwilling to give you many details. Again, conclude this portion of the interview with a brief summary and allow the patient time to make additions or corrections.

Sensitivity is key when discussing lifestyle

The final component of the health history focuses on the patient's lifestyle and social history. Many of your questions will touch upon sensitive issues. Take a moment to remind the patient that the purpose of the interview is to gather information that will help provide her with the best care possible and that all of her responses are part of her medical record and therefore strictly confidential.

Use the information you've already gathered to guide you as you ask about the patient's educational background, religious affiliation, current and past employment, and financial status.

A supportive, nonjudgmental attitude and very general inquiries may help ease the patient's anxiety or possible resentment that you are probing into areas that are too personal. For example, instead of asking how much education the patient has had, find out how she best learns new information. And, since you have already asked about her marital status, employment, and health insurance at the start of the interview, there is no need to ask these specific questions again.

You will, however, want to know if she has any concerns about any occupational health risks. Rather than asking about income in dollars and cents, ask her to describe how she sees her financial status.

Ask about current living conditions. Does the patient live alone? Are there relatives or friends in the area who would be of help to the patient if she were to have difficulty with transportation, shopping, or other activities of daily living? Or is she the main support system for an aging parent or disabled child?

Here again, some of these issues may already have been discussed when you asked about the impact or significance of the patient's current problem, so don't belabor the point.

Inquire about tobacco and alcohol intake. Ask about substance abuse in a straightforward, nonjudgmental manner. If possible, get specifics about how much of these substances the patient uses and how often.

Does the patient follow a special diet for health or religious reasons? Has she noticed any significant weight loss or gain? How much caffeine does she consume in a day? Has she noticed any change in sleep habits? Does she feel she gets enough sleep?

Finally, ask about social activities, hobbies, and her level of satisfaction with her life in general. Give the patient the opportunity to ask any questions and clarify the things that she's said.

Explain that the physical assessment will be done by another healthcare professional who may ask some similar questions about her symptoms or health history in order to gain a more in-depth understanding of her particular health problem.

Though the history is only a first step, it goes a long way toward providing you with a wealth of information you can use to develop a plan of care that will meet your patient's specific needs now and at discharge. Make the most of the encounter!

REFERENCES

1. Bickley, L., & Hoekelman, R. (1999). Bates guide to physical examination and history taking (7th ed.). Philadelphia: Lippincott, Williams & Wilkins.

2. Estes, M. (2002). Health assessment and physical examination (2nd ed.). Albany: Delmar.

3. Nettina, S. M. (Ed.) (2001). The Lippincott manual of nursing practice (7th ed.). Philadelphia: Lippincott, Williams & Wilkins.


Techniques for obtaining a thorough history

Becoming a skilled interviewer and, thus, obtaining a complete history, takes practice and a working knowledge of verbal and nonverbal communication techniques. Direct questions are most helpful when you're looking for specific information: For example: "How old are you?" "What is your date of birth?" and "Are you allergic to any medications?" These types of questions are also very useful when you are trying to clarify information: "So, the pain only occurs at night?" and "I'm not sure I understand, you say you feel you're getting crazy like your mother?"

Nondirective or open-ended questions such as "What brings you here today?" or "Why do you feel you need to be seen today?" allow the patient to tell the story and take whatever direction she wishes. Open-ended questions often yield much more information than direct questions.

Reflection, or repeating the patient's own words, is another technique the interviewer can use to prompt the patient to give more details:

"The pain was so bad, I thought I was going to pass out."

"Pass out?"

"Yes, I felt hot and then cold and very dizzy. I had to put down my groceries and sit down."1

Summarizing what the patient has said also provides an opportunity for clarification and lets the patient know you really have been listening: "You said you came in because of chest pressure that's gotten worse since the beginning of the week. On Monday morning it lasted only five minutes when you first got up. This morning it lasted an hour and you also started to feel a little short of breath. You never had this problem before, but you're concerned it might be heart trouble because your brother had the same problem and he had a heart attack. Is that correct?"1

Using a summary to introduce the transition to another phase of the interview is also helpful. "Now before we move on to discuss your past health history, I just want to go over what you've already told me and see if there's anything you'd like to add or change."

Validating a patient's concerns, offering reassurance, and being empathetic during the interview are also important because they help ease the patient's anxiety and establish trust. "Since your brother had a heart attack, I can understand why you would be very concerned about having similar symptoms." But avoid telling the patient that everything will be all right, because, in fact, it might not be and the patient may then feel that you've misled or lied to her.

To show empathy you must first identify the patient's feelings, which often may not have been directly expressed. "When you mentioned your brother's heart attack, you had tears in your eyes. Do you feel sad?"1

Nonverbal communication is also very important. Maintaining eye contact during the interview helps make the interview feel private. Short periods of silence can also help the patient collect her thoughts before continuing. During these times, just sit quietly but maintain eye contact. Looking away, appearing distracted, or fidgeting with your notes conveys a lack of interest and blocks communication.2

Be careful, though, not to overuse this technique, because in our culture, long periods of silence during conversation aren't tolerated very well and can provoke anxiety.2

Since every patient is different, some of these techniques may prove more effective than others depending upon the situation. As you become a more practiced interviewer, you'll be able to select the ones that will help you to obtain the most complete history.

REFERENCES

1. Bickley, L., & Hoekelman, R. (1999). Bates' guide to physical examination and history taking (7th ed.). (1999). Philadelphia: Lippincott, Williams & Wilkins.

2. Enelow, A., Forde, D., & Brummel-Smith, K. (1996). Interviewing and patient care. (4th ed.). New York: Oxford University Press.


 

Sally Beattie Dulak. A practical guide to a thorough history. RN Travel Nursing Today;67:TNT14.

Published in RN Magazine.

Patient Interview Questions

Tips and Sample Questions for Interviewing Patients Who Have Been Hospitalized Three or More Times in the Last Six to Nine Months (Printable version) 

Sit next to the patient at the bedside, and make eye contact. You may consider removing your white coat beforehand in order to help the patient feel comfortable opening up to you. Briefly introduce yourself and explain that you are interested in helping patients get better care. Ask the patient if he or she would mind if you ask a few questions to get to know him or her better.

If the patient does not want to talk to you, respect his or her decision. Ask if the patient would like you to come back if he or she is admitted to the hospital again. It may take some time for the patient to want to open up, and this step shows that you are committed to helping the patient on his or her own terms.

If the patient is willing to talk, here are some sample questions to help you get started. Be prepared with follow-up questions if you initially get short responses. It may take time to draw out the patient. Work more on forming a connection with the patient and getting to know him or her, rather than following a rigid script.

1. What’s your name?

2. Do you live nearby?

3. Where did you grow up? (Possible follow-ups: What did you like about growing up there? What did you dislike? Why? Are you still close with friends from those days?)

4. What are some of the things you enjoy doing? (Possible follow-ups: How often do you get to do that these days? What would make it easier for you to do this more often? What is your best memory of doing that? What do you usually do on weekends?)

5. Can you tell me a little about how you ended up in the hospital? (Let the patient tell his or her story. Allow the patient to talk for as long as he or she wishes.) (Possible follow-ups: What time of day was it? Were you alone or was someone there with you? Who took you here or called the ambulance? Was there anything different about this trip from other trips to the hospital? )

6. I noticed you’ve been in the hospital a lot lately. Would you like to talk about what else is going on with your health? (Possible follow-ups: Who do you currently talk to about your health? How do you get there? Do you feel like they understand you? Do they listen to you?)

7. Can you tell me about some of your good and bad experiences with the health care system? (Possible follow-up: What could have made that experience (even) better?)

8. Do you have any problems getting the care you need? Can you share with me some of these problems? (Possible prompts: What was it like getting to the appointment? Did you have to wait long? Reschedule? Do you have any co-pays? Not sure who you should see? Difficulty getting the medicines you need? )

9. Do you have a primary care physician? In other words, do you have a regular doctor who you can call or see when you are having less urgent health problems but don’t know what to do? (Possible follow-ups: Does what he/she prescribes to you make sense or seem like something you can do? Why or why not? What would you like the doctor to know or think about that you haven’t already discussed with him/her? Do you feel like that is something you could tell your doctor?)

10. Are there other members of your family or the community who check in on you, or to whom you can turn when you aren’t feeling well? What about social workers, case managers, or other members of your health care team? Would you mind if I contacted some of them to talk about ways to help you together?

If family members are present, you may want to include them in the conversation as well.  They can provide additional clues about the patient’s experience, background, and barriers to care.

(Printable version) 

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