History taking

Taking a history from a patient or service user is key to nursing roles in a variety of clinical settings. A complete history is necessary for the nurse to conduct an assessment, come to a valid diagnosis or generate a care and support plan (Ellis and Standing, 2023).

The Nursing and Midwifery Council requires that ‘people’s physical, social and psychological needs are assessed and responded to’ (Nursing and Midwifery Council, 2018), and a key part of this assessment process is taking the patient’s history.

The National Institute for Health and Care Excellence (NICE) (2018) states that patients have the right to have an advocate present at a care planning assessment to ensure that their wants and needs are met.

Taking a history from a patient is distinct from collecting physical data (eg measuring blood pressure, pulse rate or undertaking a physical examination), but is an equally important and complementary procedure. Taking a history involves collecting verbal data from the patient regarding their reason for visiting the healthcare facility. A thorough history may provide up to 80% of the information needed to make a clinical diagnosis (Diamond-Fox, 2021).

The nurse must first determine whether the patient needs to undertake a comprehensive or focussed assessment (Hogan-Quigley and Palm, 2021). A comprehensive assessment is appropriate if the patient is new to a care setting and a history of their care needs is required (Fawcett and Rhynas, 2012). A more focussed assessment might take place if the patient is returning to a care setting in which they are an established patient or, for example, if they are visiting an emergency department with an

Establishing a rapport with the patient, explaining the process and getting consent are fundamental to taking a patient’s history (Ingram, 2017). A simple question such as, ‘are you happy for me to take a history from you so I can better understand your needs?’ not only establishes consent, but also serves to put the patient at ease and build trust and confidence (Donnelly and Martin, 2016).

Communication is not only about asking questions but, as Lowth (2015) points out, is also about careful listening, particularly as this will allow nurses to make an accurate diagnosis based on the patient’s description of their symptoms. It is often best to ask a combination of broad, usually open questions, allowing the patient to describe their experiences and needs in their own words (Lowth, 2015), alongside more focussed, closed questions aimed at gaining a better understanding of the presenting symptoms (Ventres and Frankel, 2015). Using a combination of communication strategies means that the nurse is less likely to miss details of the patient’s condition (see

There are a number of structures or models which can be applied when taking a history. The most common of these are explored here, along with some of the mnemonics used to aid in holistic and consistent data collection (Diamond-Fox-2021). Structured history taking, often coupled with a structured physical examination, are important foundations to inform decision making about care provision (Donnelly and Martin, 2016).