SCENARIO: PT HISTORY TAKING

A new patient khadar is admitted recently to medical ward, this pt. is new and need to get his
information please take a general nursing history for this patient to get his full information.
Aim: (KNOWLEDGE) of taking history

Module name: Medical surgical Final

Candidate NO: Programme Nursing
Examiner name: Station no Date :2022/2/
S. No Possible answers Possible Scored
Marks Marks
1. Great welcome and introduce yourself to the pt. 1
2. Explain the procedure to the pt. 1
3. Always take patient consent, 1
4. Introduction and orientation, Patient identification, Patient 3*
Name, Age, Sex
5. Ask about main presenting complain by using open words 3*
6. History of present illness, Duration, Onset, aggravating 3*
factors, relieving factors, Associated symptoms
7. History of past illness, Previous similar problem, Previous 3*
hospitalization, Previous surgery, Previous blood
transfusion, Chronic problem
8. Family history, Similar condition, Chronic problem, Any 1
other family problem
9. Social history, Occupation, Marital status, Electricity and 3*
water supply,
10. Drug History, current medication Chronic medications, 3*
Drug allergy
11. Reassure the pt. 1
12. Explain when to seek health care providers care 1
13. Ask any enquiries 1
14. Encourage the pt. to give you all correct information 1
15. Documentation 1
16. Global rating 4
Total 31/31
*Essential criteria must pass at least 4 out of 6 of the essential criteria
Examiners Global Rating

4. 3. 2. 1. 0.
4= excellent 3= very good 2=clear pass. 1=borderline 0=Fail
Any comments on the student’s performance

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