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art & science clinical skills: 28

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.

Summary Preparing the environment

This article outlines the process of taking a history from a patient, The first part of any history-taking process and,
including preparing the environment, communication skills and the indeed, most interactions with patients is
importance of order. The rationale for taking a comprehensive preparation of the environment. Nurses can
history is also explained. encounter patients in a variety of environments:
Authors accident and emergency; general wards;
department areas; primary care centres; health
Hilary Lloyd is principal lecturer in nursing practice, development
centre clinics and the patient’s home. It is
and research, City Hospitals Sunderland NHS Foundation Trust,
important that the environment in practical terms
Sunderland, and Stephen Craig is senior lecturer in nursing,
is accessible, appropriately equipped, free from
Northumbria University, Newcastle upon Tyne.
distractions and safe for the patient and the nurse
Email: hilary.lloyd@chs.northy.nhs.uk
(Crouch and Meurier 2005).
Keywords Respect for the patient as an individual is an
important feature of assessment, and this includes
Assessment; Communication; History taking
consideration of beliefs and values and the ability
These keywords are based on the subject headings from the British to remain non-judgemental and professional
Nursing Index. This article has been subject to double-blind review. (Rogers 1951). Respect also involves maintenance
For author and research article guidelines visit the Nursing Standard of privacy and dignity; the environment should be
home page at www.nursing-standard.co.uk. For related articles private, quiet and ideally, there should be no
visit our online archive and search using the keywords. interruptions. When this is not possible the nurse
should do everything possible to ensure that
TAKING A PATIENT history is arguably the most patient confidentiality is maintained (Crouch and
important aspect of patient assessment, and is Meurier 2005).
increasingly being undertaken by nurses (Crumbie It is essential to allow sufficient time to
2006). The procedure allows patients to present complete the history. Not allowing enough time
their account of the problem and provides can result in incomplete information, which may
essential information for the practitioner. adversely affect the patient’s care.
Nurses are continually expanding their roles,
and with this their assessment skills. It is likely
Communication
that history taking will be performed by a nurse
practitioner or specialist nurse, although it can The importance of taking a comprehensive
be adapted to most nursing assessments. The history cannot be overestimated (Crumbie 2006).
history is only one part of patient assessment and is The nurse should be able to gather information in
likely to be undertaken in conjunction with other a systematic, sensitive and professional manner.
information gathering techniques, such as the single Good communication skills are essential.
assessment process, and nursing assessment. Introducing yourself to the patient is the first part
History taking for assessment of healthcare of this process. It is important to let patients tell
needs is not new. Many nursing theorists have their story in their own words while using active
examined health deficits (Henderson 1966, Roper listening skills. It is also important not to appear
et al 1990, Orem 1995), all of which rely on careful rushed, as this may interfere with the patient’s
assessment of patients’ needs. Other nursing desire to disclose information (Hurley 2005).
theorists identified interaction theories (Peplau Developing a rapport with the patient includes
1952, Orlando 1961, King 1981), which sought to being professionally friendly, showing interest
develop the relationship between the patient and and actively using both non-verbal and verbal
the nurse through systematic assessment of health. communication skills (Mehrabian 1981) (Box 1).
This article provides the reader with a Practitioners should avoid the use of technical
framework in which to take a full and terms or jargon and, whenever possible, use the
comprehensive history from a patient. patient’s own words.

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Crumbie 2006). Many books and articles also

BOX 1
suggest that the history should be taken in a set
Examples of non-verbal and verbal order (Douglas et al 2005, Shah 2005), however,
communication skills
it is not necessary to adhere to these rigidly.
Non-verbal Verbal Open questions It is important to use appropriate
Eye contact Appropriate language questioning techniques to ensure that nothing is
Interested posture Avoid jargon and technical terms missed when taking a history from a patient.
Nodding of head Pitch Always start with open-ended questions and take
time to listen to the patient’s story. This can
Hand gestures Rate and intonation
provide a great deal of information, although not
Clothing Volume
necessarily in a systematic order. Examples of
Facial gestures open questioning include: ‘Tell me about your
(Mehrabian 1981) health problems?’ and ‘How does this affect
you?’
Closed questions Once the patient has completed
Consent
his or her ‘story’ move on to clarify and focus
Before any healthcare intervention, including with specific questions. Closed questions provide
history taking, informed consent should be extra detail and sharpen the patient’s story.
gained from the patient. It can be obtained using Examples of closed questioning include: ‘When
various methods. However, both the Nursing did it begin?’ and ‘How long have you had it for?’
and Midwifery Council’s (NMC 2004) Code of Clarification Clarification involves recalling
Professional Conduct and the Department of back to the patient your understanding of the
Health’s (DH 2001) Good Practice in Consent history, symptoms and remarks. Summarising
Implementation Guide state that patients can the history back to the patient is necessary to
only provide consent if they are able to act check that you have got it right and to clarify any
under their own free will, have an discrepancies. Finally, asking the patient, ‘Is there
understanding of what they have agreed to and anything else?’ gives him or her a final
have enough information on which to base a opportunity to add any further information.
decision. In general, interviewing skills develop
The ability of the patient to give consent to through practice. Some helpful points of
history taking is important. Consent is governed guidance to consider include (Morton 1993):
by two acts of parliament: the Mental Capacity
! Encouraging participation and agreement.
Act 2005 in England and Wales and the Adults
with Incapacity (Scotland) Act 2000 in Scotland. ! Offering prompts and general leads.
There is currently no equivalent law on mental
! Focusing the discussion.
capacity in Northern Ireland. In addition, each
health trust will have a local policy that the nurse ! Placing symptoms or problems in sequence.
should follow. The NMC (2007a) and DH
! Using pauses effectively.
(2007a) websites provide further information on
the Mental Capacity Act 2005 and consent. ! Making observations that encourage the
patient to discuss symptoms.
The history-taking process ! Reflecting.
There are some general principles to follow when
BOX 2
gathering information from patients.
Introductions As stated earlier, always begin History-taking sequence
with preparing the environment, introducing
! The presenting complaint.
yourself, stating your purpose and gaining
! Past medical history.
consent. Once this has been completed, it is best
to begin by establishing the identity of the patient ! Mental health.
and how he or she would like to be addressed ! Medication history.
(Hurley 2005). The first information to be ! Family history.
gathered as with any history is basic ! Social history.
demographic details, such as name, age and ! Sexual history.
occupation. ! Occupational history.
Order and structure The general structure of ! Systemic enquiry.
history taking follows the process outlined in ! Further information from a third party.
Box 2. There is a consensus in medical and ! Summary.
nursing texts that it is important to have a logical (Adapted from Douglas et al 2005)
and systematic approach (Douglas et al 2005,

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art & science clinical skills: 28 Taking the history
If the structure advised by Douglas et al (2005) is
used, history taking should start with asking the
! Clarifying points by restating points raised. patient about the presenting complaint.
The presenting complaint To elicit information
! Summarising.
about the presenting complaint start by using an
There are also some techniques that should be open question, for example: ‘What is the
avoided. These are outlined by Crumbie (2006) problem?’ or ‘Tell me about the problem?’. This
(Box 3). 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
Calgary Cambridge framework
asked more specific details about his or her
Kurtz et al (2003) refined the Calgary Cambridge symptoms, starting with the most important first.
Observation Guide (CCOG) model of It is important to concentrate on symptoms and
consultation to include structuring the not on diagnosis to ensure that no information is
consultation. The CCOG is useful as it facilitates missed. Most textbooks provide a list of cardinal
continued learning and refining of consultation symptoms – those symptoms that are most
skills for the teacher and practitioner and is an important to that body system – and should be
ideal model for both ‘novice’ and ‘experienced’ asked about to ensure that a full history is obtained
nurses. Kurtz et al (2003) suggested five stages to from the patient. Box 4 provides a list of examples
summarise history taking including: of the cardinal symptoms for each body system.
Explanation and planning Giving patients When a patient reports symptoms from a
information, checking that it is correct and that specific body system, all of the cardinal
you both agree with the history that has been taken. symptoms in the system should be explored.
Aiding accurate recall and understanding For example, if a patient complains of
Making information easier for the patient using palpitations, then specific questions should be
reflection. asked about chest pain, breathlessness, ankle
Achieving a shared understanding swelling and pain in the lower legs when walking
Incorporating the patient’s perspective to to ensure that all cardinal questions relating to
encourage an interaction rather than a one-way the cardiovascular system have been covered.
transmission. Each symptom should be explored in more
Planning through shared decision making detail for clarification because this helps to
Working with patients to assist understanding and construct a more accurate description of the
involving patients in the decision-making process. patient’s problems. Direct questions can be used
Closing the consultation Explaining, checking to ask about:
and offering a plan acceptable to the patient’s
! Onset – was it sudden, or has it developed
needs and expectations.
gradually?

BOX 3 ! Duration – how long does it last, such as

minutes, days or weeks?
Examples of unhelpful interview techniques
! Site and radiation – where does it occur? Does
! Asking ‘why’ or ‘how’ questions. it occur anywhere else?
! Using probing persistent questions.
! Aggravating and relieving features – is there
! Using inappropriate or technical language. anything that makes it better or worse?
! Giving advice.
! Associated symptoms – when this happens,
! Giving false reassurance. does anything else happen with it, such as
! Changing the subject or interrupting. nausea, vomiting or headache?
! Using stereotype responses. ! Fluctuating – is it always the same?
! Giving excessive approval or agreement. ! Frequency – have you had it before?
! Jumping to conclusions.
Direct questioning can be used to ask about the
! Using defensive responses. sequence of events, how things are currently and
! Asking leading questions that suggest right answers. any other symptoms that might be associated
! Social chat: the person is expecting professional with possible differential diagnoses and risk
expertise. factors. Negative responses are also important,
(Crumbie 2006) and it is vital to understand how the symptoms
affect the patient’s day-to-day activities.

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Past medical history When a full account of the

BOX 4
presenting complaint has been ascertained,
information about the patient’s past medical Cardinal symptoms
history should be gathered. This may provide
General health ! Change in bowel habit
essential background information – for example,
on diabetes and hypertension, or a past history of ! Wellbeing ! Colour of stools
cancer. It is important to capture the following ! Energy
information when taking a past medical history: ! Appetite Genitourinary system
! Diagnosis. ! Sleep ! Pain on urinating
! Dates. ! Weight change ! Blood in urine
! Mood/anxiety/stress ! Risk assessment for sexually
! Sequence. transmitted infections
! Management. Cardiovascular system
! Chest pain Men
Begin by using questions such as, ‘What illnesses
! Breathlessness ! Hesitancy passing urine
have you had?’ Ensure that you have obtained a
full list of the patient’s past medical history and ! Palpitations ! Frequency of micturition
explore each of these in detail as with the ! Ankle swelling ! Poor urine flow
presenting complaint. It is useful to prompt the ! Incontinence
! Pain in lower leg when walking
patient by using direct questioning to ask about
! Urethral discharge
common major medical illnesses, such
as whether he or she has ever had tuberculosis; ! Erectile dysfunction
Central nervous system
rheumatic fever; heart disease; hypertension; ! Headaches ! Change in libido
stroke; diabetes; asthma; chronic obstructive ! Dizziness
pulmonary disease; or epilepsy. Musculoskeletal
Mental health According to the NHS ! Vertigo
Confederation (2007), one in four people will ! Sensations ! Joint pain
experience mental health problems at one time ! Fits/faints ! Joint stiffness
during their life. This figure demonstrates that ! Weakness ! Mobility
nurses are likely to encounter mental health issues ! Gait
! Twitches
frequently. By using skills previously highlighted,
! Tinnitus ! Falls
and with a supportive and professional approach,
the nurse can enquire with confidence about the ! Visual disturbance ! Time of day pain
patient’s current coping strategies, such as ! Memory and concentration
anxieties over health problems (suspicion of changes Respiratory system
malignancy, impending surgery or test results) or
! Shortness of breath
more developed mental health issues, such as
Endocrine ! Cough
bipolar disorder or schizophrenia.
Further clues can be gained from the patient’s ! Excessive thirst ! Wheeze
prescribed medication history or previous ! Tiredness ! Sputum
hospital admissions. The nurse may feel anxious ! Heat intolerance ! Blood in sputum
about enquiring about mental health issues, but ! Hair distribution
it is an important part of wellbeing and should be ! Pain when breathing
! Change in appearance of eyes
assessed.
Medication history This is crucially important Women
and should consider not only what medication Gastrointestinal system
! Onset of menstruation
the patient is currently taking but also what he or ! Dental/gum problems
she might have been taking until recently. ! Last menstrual period
! Tongue
Because of the availability of so many ! Timing and regularity of
medications without prescription, known as ! Difficulty in swallowing periods
over-the-counter drugs, remember to ask ! Painful swallowing ! Length of periods
specifically about any medications that have ! Nausea ! Type of flow
been bought at the pharmacy or supermarket, ! Vomiting
including homeopathic and herbal remedies. For ! Vaginal discharge
each medication ask about: the generic name, if ! Heartburn ! Incontinence
possible; dose; route of administration; and any ! Colic ! Pain during
recent changes, such as increase or decrease in ! Abdominal pain sexual intercourse
dose or change in the amount of times the patient (Adapted from Douglas et al 2005)
takes the medication.

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art & science clinical skills: 28 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
Concordance with medication is an important should ask about past and present patterns of
part of taking a medication history. Finding out the drinking alcohol. Ewing (1984) suggested use of
level of concordance and any reasons for non- the CAGE system, in which four questions may
concordance can be of significance in the future elicit a view of alcohol intake (Box 5). Hearne et
treatment of the patient. Finally, ask about any al (2002) considered it to be an efficient
allergies and sensitivities, especially drug allergies, screening tool.
such as allergy or sensitivity to penicillin. It is The nurse should be wary of patients who are
important to find out what the patient experienced, evasive or indignant when asked questions about
how it presented in terms of symptoms, when it alcohol consumption. A mental note should be
occurred and whether it was diagnosed. taken to ask again at a later stage and to consider
Family history Some disorders are considered physical evidence of alcohol intake during the
familial; a family history can reveal a strong physical examination. Many patients do not
history of, for example, cerebrovascular disease recognise units of alcohol and will talk in
or a history of dementia, that might help to guide measures and volume for which the nurse will
the management of the patient. Open have to have a mental ready reckoner to calculate
questioning followed by closed questioning can the weekly alcohol consumption. The DH
be used to gather information about any website provides useful guidance on this (Box 6).
significance in the patient’s family history. For
example, start with an open question such as: BOX 5
‘Are there any illnesses in the family?’ Then ask
The CAGE system
specifically about immediate family – namely
parents and siblings. For each individual ask ! Have you ever felt the need to Cut down?
about diagnosis and age of onset and, if ! Have people Annoyed you by criticising your
appropriate, age and cause of death. drinking?
Social history A patient’s ability to cope with a
! Have you ever felt Guilty about your drinking?
change in health depends on his or her social
wellbeing. A level of daily function should be ! Have you ever had a drink to steady your nerves in
established throughout the history taking. the morning (Eye opener)?
The nurse should be mindful of this level of (Ewing 1984)
function and any transient or permanent change
in function as a result of past or current illness.
BOX 6
Questions about function should include the
ability to work or engage in leisure activities if Equivalent units of alcohol
retired; perform household chores, such as
housework and shopping; perform personal ! A pint of ordinary strength lager, for example,
Carling Black Label, Foster’s = 2 units.
requirements, such as dressing, bathing and
cooking. In particular, with deteriorating health ! A pint of strong lager, for example, Stella Artois,
a patient may have needed to give up club or Kronenbourg 1664 = 3 units.
society memberships, which may lead to a sense
! A pint of ordinary bitter, for example, John Smith’s,
of isolation or loss. Boddingtons = 2 units.
Nurses should consider the whole of the
family when exploring a social history. ! A pint of best bitter, for example, Fuller’s ESB,
Relationships to the patient should be explored, Young’s Special = 3 units.
for example, is the patient married, is his or her ! A pint of ordinary strength cider, for example,
spouse healthy, do they have children and, if so, Woodpecker = 2 units.
what age are they? The health and residence to
the patient should be known to understand ! A pint of strong cider, for example, Dry Blackthorn,
Strongbow = 3 units.
actual and potential support networks. Other
support structures include asking about friends ! A 175ml glass of red or white wine is around
and social networks, including any involvement 2 units.
of social services or support from charities, such
! A pub measure of spirits = 1 unit.
as MIND (National Association for Mental
Health) or the Stroke Association. ! An alcopop, for example, Smirnoff Ice, Bacardi
The social history should also include enquiry Breezer, WKD, Reef is around 1.5 units.
into the type of housing in which the patient lives. (DH 2007b)
This should include if the accommodation is

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Nurses should be mindful that increased Recreational drugs are those that are used
alcohol consumption might be a reaction to the regularly and which are a focus of a leisure
health stressors affecting the patient during activity without interrupting the user’s abilities
adjustment to recent changes in health. It could and lifestyle (Vose 2000). Drug dependence
also be that the patient is drinking excessively to is when recreational use reaches a level of
act as both a physical and emotional analgesic. ‘tolerance’. This is the point where or when the
Careful, but purposeful, questioning using a use of the drug requires larger more regular usage
mixture of the skills outlined should encourage to acquire the same initial effect.
the nurse to have confidence to broach the topic Professional and appropriate behaviour by
of alcohol dependence. Specific questioning the nurse, using careful and tactful questioning,
should include the quantity and type of alcohol is needed to enable the patient to feel comfortable
consumed and where the majority of the drinking in disclosing drug use. The nurse may uncover
takes place, whether in isolation or company. unpleasant or illegal actions by the patient in
Smoking It is documented that smoking causes their pursuit of obtaining drugs or being under
early death in the population and no safe the influence of drugs.
maximum or minimum limit, unlike alcohol, has Sexual history This can be a difficult subject to
been identified. Nurses should ask questions that broach and it is not always appropriate to take a
identify the history of the patient’s smoking. full sexual history (Douglas et al 2005). Where
Traditionally questions surrounding smoking relevant ask questions in an objective manner,
include: ‘What age did you start smoking?’, but acknowledge the sensitivity of the subject by
‘What kind of cigarettes do you smoke?’, ‘How starting with: ‘I hope you don’t mind but I need to
many cigarettes a day do you smoke?’, ‘Do you ask some questions about ...’
use roll ups or filtered?’ and ‘Are they low or high In men, questions regarding sexual history can
tar content?’. be asked as part of the genitourinary system
Patients will often be unclear about the history and should include any previous urinary
amount they smoke, but with persistence, ‘pack tract infections, sexually transmitted infections
years’ – now the standard measure of tobacco and treatments provided. In women date of
consumption – can be calculated (Prignot 1987). menarche, regularity and character of periods,
Pack years is a calculation to measure the amount pregnancies, live deliveries and terminations or
a person has smoked over a long period. other losses should be recorded. Women should
The pack year number is calculated by also be sensitively asked about any infections and
multiplying the number of packs of cigarettes treatments. High-risk sexual activity, such as
smoked per day by the number of years the unprotected sexual intercourse should be
person has smoked. For example, one pack year addressed in both genders. In men and women
is equal to smoking one pack per day for one year, an enquiry should be made regarding libido,
or two packs per day for half a year, and so on. increased or diminished, to reflect both
If an individual smokes three packs per day for psychological and endocrine systems.
20 years then this would amount to 3 packs per Occupational history Taking a history should
day x 20 years = 60 pack years. include information on previous and current
Roll-up cigarettes are more difficult to employment. This is important as aspects of
calculate as these are made by the patient and are employment other than the job itself can
not a standard size. Tobacco is usually sold in influence social wellbeing if illness precludes a
grams but verbalised in ounces. Approximate return to work. For example, employment in
tobacco amounts can be calculated (Box 7). heavy industry may lead to respiratory
Illicit/recreational drugs In the British Crime problems or joint problems. Although
Survey, Roe and Man (2006) identified that just occupations may date back several years,
under half (45.1%) of all 16-24-year-olds have exposure to some products may have a long
used one or more illicit drugs in their lifetime, incubation period, such as resultant
25.2% have used one or more illicit drugs in the mesothelioma after asbestos exposure.
last year and 15.1% in the last month. Past and current employment will also
provide details of financial stability of the home.
BOX 7 Retired patients may have financial limitations,
Approximate calculation of tobacco as will patients who are currently unemployed.
Increased anxiety can be present in patients who
1 ounce = 28.34 grams find themselves unable to work because of
2 ounces = 56.69 grams sudden illness or having to care for a relative or
3 ounces = 85.04 grams partner. Questions about a patient’s financial
condition should be unhurried and handled
A ‘standard’ pouch of tobacco is equivalent to
sensitively by the nurse. This might include
50 grams
discussion about social support and benefits

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&
art & science clinical skills: 28 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
because hospitalisation can alter the patient’s the treatment and management of a patient.
eligibility for benefits. Alternatively, the prescribed medication history
Systemic enquiry The final part of history taking may be checked with the GP practice if the patient
involves performing a systemic enquiry. This is not able to give a full history.
involves asking questions about the other body
systems not discussed in the presenting
Conclusion
complaint. The purpose of this is to check that no
information has been omitted. It involves This article has presented a practical guide to
systematic questioning of symptoms relating to history taking using a systems approach. It
cardiovascular, respiratory, gastrointestinal, considered the key points required in taking a
genitourinary, locomotor and dermatological comprehensive history from a patient, including
aspects and might yield important clues about preparing the environment, communication
the cause of the presenting problems. The skills and the importance of order. While this
cardinal symptoms for each system are outlined article provides the knowledge for taking a
in Box 4 and questioning should focus on the history, the best method of achieving skills in
presence or absence of these symptoms. It is history taking is through a validated training
expected at this stage to receive a negative answer course with competency-based assessments.
to symptoms not already discussed. However, a The history-taking interview should be of a
positive response to any of the questioning high quality and must be accurately recorded
should be investigated using the same method as (Crumbie 2006). Nurses should be familiar with
in the presenting complaint. the NMC Code of Professional Conduct
It is important not to overlook the value of regarding competence, consent and
obtaining a collateral history from a friend or confidentiality (NMC 2004). The novice history
relative. If necessary, and with the patient’s taker’s records should adhere to the NMC’s
permission, use the telephone to obtain this (2007b) guidance on record keeping NS

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