The patient interview is a cornerstone of medical practice, serving as the foundation for accurate diagnosis, effective treatment planning, and the establishment of a therapeutic relationship. Its primary goals are to gather comprehensive information about the patient’s health history, current symptoms, and concerns, while fostering trust and rapport (Myrick et al., 2019).
Components of the Patient History
The patient history is a detailed record of a patient’s past and present health status. It consists of several key components:
- Chief Complaint: This is a concise statement of the primary reason for the patient’s visit. It should be recorded in the patient’s own words and include the onset, duration, and severity of the symptoms.
- History of Present Illness (HPI): A detailed chronological account of the chief complaint, exploring its onset, location, character, severity, duration, associated symptoms, aggravating and relieving factors, and past medical treatments.
- Past Medical History (PMH): A comprehensive list of the patient’s previous illnesses, surgeries, hospitalizations, and allergies.
- Medications: A complete list of current medications, including prescription and over-the-counter drugs, herbal supplements, and vitamins.
- Allergies: A detailed record of any allergies, including medications, food, and environmental allergens.
- Surgical History: A list of previous surgeries, including dates, types of surgery, and complications.
- Immunization History: A record of the patient’s immunization status.
- Social History: Information about the patient’s lifestyle, including occupation, smoking, alcohol use, drug use, sexual history, and marital status.
- Family History: A record of the health status of the patient’s family members, including any significant illnesses or genetic disorders.
- Review of Systems (ROS): A systematic inquiry about each body system to identify any additional symptoms or concerns not previously mentioned.
An Incident of Improper Blood Pressure Measurement
During my early nursing practice, I encountered a patient with significantly elevated blood pressure readings. I repeated the measurement multiple times, obtaining consistently high results. Concerned about the patient’s health, I prepared to initiate immediate care. However, a more experienced colleague suggested rechecking the blood pressure using a different arm and ensuring the patient was relaxed.
Upon repeating the measurement, the blood pressure readings were within normal limits. This incident highlighted the importance of proper technique and the potential for errors in measurement. I learned the significance of using the correct cuff size, ensuring the patient is relaxed, and avoiding errors in technique that can lead to inaccurate results.
Cultural Barriers in Patient Assessment
Cultural differences can pose significant challenges in patient assessment. For instance, when caring for a patient from a culture with different health beliefs, it is crucial to be respectful and avoid making assumptions. A patient may hesitate to disclose information due to cultural taboos or language barriers.
In one instance, I encountered a patient from a culture where discussing mental health is stigmatized. The patient presented with physical symptoms but seemed reluctant to engage in open conversation about their emotional state. To overcome this barrier, I used open-ended questions, active listening, and demonstrated empathy. I also involved a cultural interpreter to facilitate communication and build trust.
By understanding and respecting cultural differences, healthcare providers can improve patient outcomes and build stronger therapeutic relationships
