Patient history taking is an essential dialogue between healthcare providers and patients, aimed at collecting vital information to inform treatment. The process involves a structured interview covering biographical data, health status, and various histories, adhering to a respectful communication model. Effective history taking requires good rapport, empathy, and appropriate questioning techniques to accurately understand patient concerns.

1. Patient history taking
HISTORY TAKING

2. Introduction
 A history taking (Interview) is a dialogue conversation
between two individuals
 A patient history taking is an interview made between a
nurse/clinician and patient in order to obtained the
detailed and vital information of someone who is sick
from the patient him/her self or relatives/police
officer/good Samaritan, which involves asking
appropriate questions to children, young people, old
and/or their families to assist the subsequent care.
 It is a process of collecting the detailed information
about a patient - including their biographical data,
present health status, past medical history, family
history, personal situations, social history and a review
of all body systems.

3.  Medical history is important because when general
practitioners (GPs ) have more information about a
patient's medical history, health professionals can deliver
the most appropriate and effective treatment or support for
their concerns.
 The aim of history taking will enable the clinician to
organize the patient's story, filter the information which
links to common musculoskeletal disorders by means of
clinical reasoning, to fully understand the patient's present
health status and to form a provisional diagnosis.

4. How do nurses take history?
 A patient history taking should be in the RESPECT model.
 Widely used to promote nurses and clinicians' awareness of
their own cultural biases and to develop health care providers'
rapport with patients from different cultural backgrounds.
This will includes seven core elements:
 Rapport (relationship)
 Empathy,
 Support,
 Partnership,
 Explanations,
 Cultural competence

5.  A comprehensive interview gives nurses insight into a
patient's physical status through observation and the
measurement of vital signs and self-reported
symptoms.
 It includes a medical history, a general survey and a
complete physical examination.

6. How do you start a patient interview?
 The nurse should start the interview by greeting the
patient by name, making sure you are pronouncing the
patient's name correctly, asking how he or she prefers
to be addressed, and adding a title to his or her name, if
preferred, will indicate your interest in the patient and
show that you care.

7. What kind of questions should be asked
early in a patient interview?
 Frequently used opening ended questions include;
 "What problems brought you to the hospital today?"
or "What kind of problems have you been having
recently?" or "What kind of problems would you like
to share with me?" These open-ended, nondirective
questions encourage the patient to report any and all
problems.

8. How do I stand out during medical interview?
 Be enthusiastic/ exited
 Be respectful and well-mannered to everyone you meet.
 Don't be arrogant.
 Prepare answers to common questions ahead of time.
 Watch your body language.
 Stand out, but not with your clothes.
 Ask questions.
 Is it OK to take notes during interview?
 It can also be perfectly acceptable to take notes during an
interview. If you are thinking about doing this, you might
want to double-check with the interviewer as you arrive at
your meeting that it is okay for you to take notes during your
conversation.

9. Medical Interview Mistakes
 Sounding too rehearsed.
 Sounding like you're reading your application or
resume.
 Dressing inappropriately.
 Not taking the time to think before answering the
question.
 Not staying on topic.
 Being negative.
 Not putting on a smile.
 Not having good, informed questions to ask.

10. History taking components
 Present Complains
 Past Medical History
 Drug History
 Family History
 Personal and Social History
 Systems Review Ideas,
 Concerns
 Expectations

11. History Taking Details gathered during
interview with patient
 Look confidently, Welcome the patient ,greet the
patient, Shake hand with patient, Introduce yourself to
patient– I am so, a student nurse .
 Welcome him/her and prepare and keep the patient in a
comfortable position.
 Provides account of medical, social events in patient's
life ,Indicates environmental factors that have an
impact on the condition
 Check patient details, wash Hands before procedure,
stand/sit right-hand side of bed

12.  Presenting Complaint
ASK OPEN ENDED QUESTIONS: “Why have you come
in today?” “Could you tell me more about your problems?
- Ask chief complaint with duration, acute or gradual?
- History of present illness
 Example Chest pain – 2 months. Ask
Site of pain , onset, acute or gradual.
 Characteristics of pain – feeling pressure, dull, stabbing,
shooting ,Radiation.
 Severity –does the pain interfere with work or sleep?
 Does Pain associated with nausea, vomiting, sweating e.g.
angina

13.  Past Medical History
 Ask for Previous illness,
 Medical conditions
 Hospitalizations
 Serious Illnesses / injuries
 Any operations (if yes, when it was done and what was
the problem)
Drug History
 Current medications:
 Prescribed
 Over-the-counter
 Name
 Dose
 Frequency ALLERGIES, Recreational drugs

14. Family History .
 Ask about Parents – father and mother are alright
 Ask if Anyone in family had similar problem?
 Any serious illnesses in the family?
 Any history of hypertension, diabetes mellitus, cancer
 If there was history of death – what was the cause of
death.
 How many brothers and sisters you have? Are they
alright?.

15.  Personal history
Ask about job. Are you married ?How many children do you
have? Their age? Are they fine? Who lives at home – partner?
Children? Religious status, educational levels, address.
 Social history
 Ask about smoker/not, Current smoker? , Past smoker? , How
many years? , Cigarettes/ marijuana? , How many per day?
 Do you drink alcohol? , What? Wine? Beer? , How much per
day?
 Travel, pet, animal contact,
 If patient is old – ask about where he lives e.g. ground floor or
upstairs ,Any difficulties regarding toilet, cooking, shopping?
 Home circumstances

16.  Systems Review
 Fits, faints, Headaches , Vision problems , Shortness
of Breath (SOB) , Cough – blood , Joint or muscle
pain, Skin rashes , Lumps , Blood in urine , Menstrual
problems,
 CNS (central nervous system) ,RS (respiratory
system), GU (genitourinary system), GI
(gastrointestinal system),
 Change in bowel habits – blood , Nausea or vomiting
 Weight loss
 Chest pain , “Heart fluttering” (palpitations) , Ankle
swelling CVS (cardiovascular system)
 “Do you have any questions?”
 THANK the patient!!!!!

17.  Any Question?
 Thank you for listening
 Prepared by Esther kindishe
 RN. BScN, MScN
 november - 2023