• To recognise the importance of taking a patient history as part of the diagnostic process
• To familiarise yourself with the process of taking a patient history
• To understand the communication skills required to take a patient history effectively
Rationale and key points
A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure.
• History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment.
• Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity.
• By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy.
Reflective activity
‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:
• How this article might improve your practice when taking a patient history.
• How you could use this information to educate nursing students or colleagues on taking a patient history.
Emergency Nurse. doi: 10.7748/en.2024.e2209
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Butler S (2024) How to take a comprehensive patient history. Emergency Nurse. doi: 10.7748/en.2024.e2209
DisclaimerPlease note that information provided by Emergency Nurse is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Published online: 30 July 2024
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