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This paper is an evaluation of the article by Lloyd, H., & Craig, S. called "A Guide to Taking a Patient's History, Clinical Skills" published in 2007 in a journal Nursing Standard, volume 22, issue 13, pages 42-48. The article provides an outline of acquiring patient’s record associated with nursing. It suggests that there are specific questions that have to be asked in the process of writing down patient’s medical history. In the article, Lloyd & Craig provide a suitable guideline on how these questions should be posed and what should actually be asked. There is also a general outline of cardinal symptoms that are associated with specific body systems.
In this article Lloyd & Craig have put down a systematic applicable lead that can be used by nurses to write down patients' medical history. The article presents relevant facts that would be of great significance to record a detailed history of a patient. The health assessment procedure and rationales discussed are shown in the table below:
|1.||Preparing the environment|
|2.||Having proper communication skills|
|3.||Getting consent from the patient|
Health assessment tools and/or strategies are presented as a history-taking sequence, which includes procedures like presenting a complaint, past medical history, mental health, medication history, family history, social history, sexual history, occupational history, systemic enquiry, further information from a third party, and summary.
The authors have also introduced the Calgary Cambridge Observation Guide (CCOG). This is a model that is useful in the process of obtaining information from the patient while using the health assessment tools mentioned above. According to the authors, it is important since it helps nurses to continue getting more information and at the same time using this information to try to get to the root of the problem at hand.
The five stages involved in the CCOG process are shown in the table below;
|Explanation and planning||Recording patients’ information, checking that it is correct, and that a doctor and a patient both agree with the history that has been recorded.|
|Aiding accurate recall and understanding||Making information easier for the patient to understand by using reflection.|
Achieving a shared understanding
|Incorporating patient's perspective to encourage an interaction rather than a one-way transmission.|
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 patient's needs and expectations.|
In the article, the writers have exhaustively illustrated the process of note taking. This is because they were able to place all the necessary tools in a manner that helped the nurse to continually learn about the current problem that had to be diagnosed. This was done so that at the end they could determine the real problem. The authors have also gone ahead to give some tips on effective communication skills that can be used to establish a good relationship with the patient. This makes it easier for the nurse to establish trustful relationships with the patient for the purposes of confidentiality and also to make the patient feel comfortable throughout the interview. It also makes it easier for the nurse to acquire a lot of critical information from the patient to give the right diagnosis. The writers have not, however, clearly shown how one can use direct questions in order to obtain information that the patient may be trying to conceal. For example, there may be an instance where a nurse may feel that there is a symptom that is not being mentioned since they cannot get any good combination to diagnose a disease. The authors have not described methods that can be used in order to obtain information from the patient in such case. It s important that the authors try to outline the process that would be most suitable in order to help nurses dig for some concealed information without annoying the patient.
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The article was indeed interesting to me. This is because the nurses have been given an opportunity to remain in touch with the patient throughout the interview. The chronology order of the tools being used to get the history makes it easier to perform a critical analysis of the problem. This also enables nurses to determine all possible causes of the symptoms experienced by the patient by using the detailed procedure. It also enables the nurse to remain within the limits to avoid annoying the patient. This is because the nurse already has a personal history of the patient and will thus be able to handle patients of different demographics e.g. behavior, beliefs, and even social reasons.
Health assessment is beneficial since it shows how to get the right information to avoid making a wrong diagnosis. This is to avoid giving the patients wrong medication that would continue harming them and thus worsening their illnesses. It also enables the nurse to get to the core of the problem to know the most effective methods to use to treat the illness.
Health assessment strategy was well explained. This is because the authors were able to present the nurse with suitable screening tools that can be used to get to the core of the problem. By continuously employing these tools, the nurses continue to gain more knowledge on the probable cause of the symptoms. The assessment strategy is able to expand the span over which it is necessary to gather correct facts to arrive at a correct diagnosis. It is appropriate to mention that more research articles must be written about this area of health assessment. This is because it is important that nurses are able to make the patient discuss any symptoms they may be ashamed to disclose. A suitable process that can be used must be developed in order to overcome this problem that is likely to be encountered. The process must ensure that nurses do not interfere with the personal life of the patient against patient's will.
Nurses who are just starting their careers would be a good audience for the information presented in this article. This is because it will help them build knowledge of what is expected of them while recording patient’s medical history. It will make it easier for them to determine the problems and develop their interviewing skills.
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The major benefits of health assessment strategy discussed above are that it allows for a proper diagnosis and also ensures provision of the correct medication to avoid putting the life of the patient at risk. The strategy is able to do this since there are many facts that are unearthed, and this presents the nurse with an opportunity to continuously build knowledge about patient’s current problem based on previous occurrences narrated by the patient. It thus makes it safe for patients too since it helps ensure safety of their lives.