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NURSING HISTORY TAKING

A. DEFINITION
In OH, taking a history is an essential part of an OH nurses work. Nurses
often find they are having to start from scratch with new employees and management
referrals, particularly if they are working for an OH provider where the workforce is
not known. This article explores how OH nurses should go about taking a history and
making a functional assessment.
As taking a history is not part of nurses initial training, it is a new skill that has to
be learnt on the job. It is needed to make an accurate assessment of the situation and
to answer the question: Is this person fit to undertake their work?
This is different to the doctors role when taking a history. Along with examination
and investigations, the doctor has to arrive at a clinical diagnosis. The ability to make
an assessment of peoples health, collect, collate and report data and information are
all part of an OH nurses competencies (Royal College of Nursing, 2011).
The OH nurse then has to prepare a suitable report advising management of fitness or
otherwise of the client without breaching confidentiality, unless the client has signed a
disclosure agreement.
Fawcett and Rhymnas suggest that history taking in its simplest form involves asking
appropriate questions to obtain clinical information. Medical textbooks (Washer,
2009)say that there is no single and correct way to take a history and suggest the
sequence outlined in box 1, although not all of the steps will be necessary for an OH
assessment.
B. PURPOSE
During a clinical assessment, a patients history can be the key to helping an
OH professional decide if someone is fit for work or not. Greta Thornbory explains
how best to conduct the process.

Taking a patients history has traditionally been regarded as the domain of their
doctor. How ever, since the introduction of the nursing process in the 1970s by the
Department of Health, which includes the assessment of patients, the nurse has been
required to obtain some sort of patient history as well as their experiences, any signs
and symptoms and current health status (Fawcett and Rhymnas, 2012).
a.

past medical history

b. any drug use and allergies


c. social and personal history
d. family history
C. METHODE OF DATA COLLECTION
1. Comunication
For nurses, some of the essential skills, such as communication, are
part and parcel of everyday practice and do not require much of an investment
to maintain. Shah (2005) says that communication skills are particularly
important when opening and closing a consultation and that, when taking a
history, care should be taken with:
a. questioning and the use of open and closed questions
b. non-verbal language
c. active listening
d. showing respect and courtesy
e. showing empathy
f. being culturally sensitive

In OH it is important to introduce yourself in a warm and friendly manner and to


make your client feel at ease, particularly when they may have been referred to OH to
establish whether or not there is a health reason for frequent absence.
New employees are keen to get the job and employees referred by management
maybe very apprehensive. Those of us who have been in OH for a number of years
accept that our profession is not always well understood, and the first few minutes of
a consultation may well be taken up with explaining the reasons for the appointment
and allaying fears and anxieties.
It is then useful to obtain some background information on the person, including their
full name to avoid confusion with others of the same or similar name and their
age, date of birth and occupation. Following recent legislation, people are concerned
about asking someones age as they believe it is unlawful. This is incorrect the
Equality Act 2010 prevents discrimination against someone on the ground of age.
2. Taking notes
When taking a history, it is necessary to make notes but these should be
brief, not an essay. Ensure each sheet of paper used has the patients name on it
and that every separate entry you make is dated and signed. It is also a good idea
to add your name to the document for the purposes of identification.
Patient notes are a legal document and it helps if they are legible. There will be
times where you want to quote exactly what the individual says, but the whole
interview should not be a dictation session.
If used, abbreviations must be intelligible to anyone who might need to read your
notes for example, a lawyer years after you have left the post.
If you have a good memory and lots of time, you can write up your notes after the
employee leaves. The usual practice is to jot down notes as you go along, unless
there is a need to show that you are listening intently to a sensitive matter.

3. Presenting situation
First, establish why the person is in front of you. This should be clear if
there is a proper management referral system in place that ensures the employee
has signed their agreement to the referral. A template referral form is given in
Employment Law and Occupational Health: A Practical Handbook (Lewis and
Thornbory, 2010).
Listen carefully to what the patient has to say and encourage them to
continue the story right up to the present day. Record details of the patients own
words, not just what you think they said.
4. History of the situation
You then need to note down what they have said and get it in
chronological order. You may need to clarify at times, such as when the patient
says they had flu and whether it was actually flu or just a cold.
Establish what investigations and treatment were given and what the person had
been told by their GP or specialist. Do not forget to ask about what medicines,
either prescribed or over the counter, they are taking. Beware of asking what drugs
they are taking as this may be misconstrued as meaning illegal drugs it is better
to ask what medication they are taking.
5. Functional assessment
If the person is referred to you for assessment of their ability to
undertake certain tasks, it is worth considering the five steps of disability analysis
(Ellis, 2008) :
1) The functional history considers what the individual is capable of and
not what they are incapable of. Take a positive approach.
2) Observe what you can see the patient is capable of doing.
3) Conduct a focused examination of the patients physical problems, if
necessary.
4) Consider all available evidence, including GP and specialist opinions
where necessary, in a logical reasoning of evidence.

5) Ustify your opinions based on the evidence of all the above.

The prime objective for the disability analyst in this process is not to diagnose
and treat, but to assess the functional effects of a persons condition on day-to-day
living.
In disability analysis, history taking focuses on day-to-day living rather than on a
clinical history, although basic clinical information is still needed. The precise
diagnosis is not critical.
In terms of the impact on daily life, it is the functional effects of the condition that are
more important. We obtain a functional history based on the individuals day-to-day
activities and any difficulties or restrictions that they have with those actions.
That history focuses on an in-depth account of the persons normal activities including
interests, hobbies, household chores, shopping, cooking, social activities and holidays.
We call this the typical day approach. This approach is a very useful method of
obtaining information about the individuals regular activities and habits.
It moves away from the clinical focus where we find out about the symptoms and
signs related to a particular illness.
Although we use the term typical day, we do not limit the history to a single day,
but also refer to less frequent activities occurring weekly, monthly or sometimes even
annually.
For OH nurses it may also be useful to consider the activities of daily living as
described by Roper, Tierney and Logan (1980), on which their model of nursing is
based (see box 2).
When assessing people, it is important to use good listening techniques. Remember
that appropriate eye contact and suitable body language leave a lasting impression
use clear, familiar and understandable language and show interest in the individual.
Allow the patient to express their needs as fully as possible and always explain what
is being done throughout the assessment.

During the assessment, remember to summarise, review and clarify note the manner
in which something is said as well as what was said. Try to use an open questioning
style, using closed questions to clarify facts or to redirect the interview. Also use
positive body language throughout the assessment.
Observed behaviour is quite important. The observation process starts as soon as you
meet the individual. For example, information could be gathered on the patients
ability to hear when their name is called in the reception area.
Further observation could provide evidence about other areas such as lower-limb
function when rising from a chair and walking to the consulting room, upper-limb
function when the patient is carrying a bag or whether or not they have any
difficulties opening doors, and other areas of functional ability.
The aim here is to give reasoned advice by using knowledge of the history and effects
of the conditions present in order to predict the likely effects on the individuals
functional ability.

D. CONCLUTION
In OH, taking a history is an essential part of an OH nurses work. Nurses often find
they are having to start from scratch with new employees and management referrals,
particularly if they are working for an OH provider where the workforce is not
known. This article explores how OH nurses should go about taking a history and
making a functional assessment.
The purpose of nursing history taking is sort of patient history as well as their
experiences, any signs and symptoms and current health status.

REFERENCES

Fawcett T, Rhymnas S (2012). Taking a patient history: The role of the nurse. Nursing
Standard; vol.26, issue 24, pp.41-46.

Royal College of Nursing (2011). Occupational health nursing: career and competency
development.

Washer P (2009). Clinical Communication Skills. Oxford: Oxford University Press.

Nayankumar S (2005). Taking a history: Introduction and the presenting complaint.


Student BMJ; vol.13, pp.309-352.