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Patient assessment: effective consultation and history taking

Article in Nursing standard: official newspaper of the Royal College of Nursing · October 2008
DOI: 10.7748/ns2008.10.23.4.50.c6677 · Source: PubMed

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p50-56w4 26/9/08 11:11 am Page 50
learning zone
CONTINUING PROFESSIONAL DEVELOPMENT
Page 58 Page 59 Page 60
Patient consultation Respiratory assessment Guidelines on how to
multiple choice practice profile by write a practice profile
questionnaire Noreen Macfarlane
Patient assessment:effective
consultation and history taking
NS462 Kaufman G (2008) Patient assessment: effective consultation and history taking. Nursing
Standard. 23, 4, 50-56. Date of acceptance: August 1 2008.
Summary
This article explores patient consultation with specific reference to
the Calgary-Cambridge consultation guide. It provides an overview
of history taking and explores the patient’s perspective during
the consultation. The article also discusses the skills required to
provide information effectively. In addition, the article addresses
‘safety netting’ and emphasises the interdependence of
communication and consultation skills.
Author
Gerri Kaufman is lecturer, University of York. Email: gk8@york.ac.uk
Keywords
Communication skills; History taking; Patient consultation
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
Aims and intended learning outcomes
This article aims to give nurses and other
healthcare professionals an insight into the
Calgary-Cambridge consultation guide. After
reading this article you should be able to:

Discuss the factors that need to be considered
when preparing for a consultation.

Recognise the key skills required to initiate the
consultation and identify the patient’s problem.

Describe the areas of information that need to
be covered to take an accurate history.

Outline effective strategies for providing
information to patients to aid accurate recall
and understanding.
50 october 1 :: vol 23 no 4 :: 2008

Discuss the factors that need to be addressed in
‘safety netting’.
Introduction
A consultation is a private and intimate
interaction between clinician and patient. It
assists in the diagnosis of health problems in
clinical settings and has traditionally been the
domain of medical practitioners. However,
as nurses expand the boundaries of their practice
in areas of first contact care, non-medical
prescribing and specialist roles, effective
consultation and history-taking skills are
becoming increasingly important.
A consultation provides an opportunity to
establish a therapeutic relationship with patients
and listen to their story with an unfolding of
symptoms, problems and feelings. However,
patients tell their stories in different, usually
unstructured, ways (Clark 1999). The use of
a model can help to provide structure and give
direction to a consultation. Without the use of
a model, practitioners may omit to ask key
questions and overlook information that is
essential for diagnostic accuracy and safe
practice (Clark 1999).
There are many consultation models but one
that can be applied to most clinical settings is
the Calgary-Cambridge guide developed by
Silverman et al (2004). The guide provides an
easy-to-use structure that complements nursing’s
traditional holistic assessment approach (Munson
2007). It consists of five main sections that run in
sequence throughout the consultation, with
physical examination of the patient situated
between the second and third sections (Figure 1).
Running parallel to these sections are two areas
that relate to structuring the consultation and
developing a relationship with the patient. These
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FIGURE 1
The Calgary-Cambridge consultation guide (Adapted from Kurtz et al 2003)

1. Initiating the session

Preparing for the consultation

Establishing a rapport with the patient

Discovering the reason/s for the consultation

2. Gathering information
Building the relationship

Providing structure
Exploring the patient’s perspective
Attending to non-verbal
in the consultation
Exploring the biomedical perspective behaviours

Exploring background information
Involving the patient

3. Physical examination

4. Explanation and planning

Planning decision making together

Providing appropriate information

Using strategies that aid accurate
recall and understanding

5. Closing the session

Planning

Final checking

Safety netting

areas contain skills that are used continuously
throughout the consultation. This article explores
the following sections of the guide:

Initiating the session.

Gathering information.

Explanation and planning.

Closing the session.
Initiating the session
Initiating the consultation in the
Calgary-Cambridge guide has unique and
separate objectives that must be completed
before moving on to the main history-taking or
information-gathering session. It involves
preparing for the encounter, establishing
a rapport with the patient and identifying
the reason for the consultation.
Chafer (2003) reminds us that a lack of
attention to the pre-consultation period can
adversely affect clinical reasoning, perceptual
skills and the ability to perform effectively and
impartially in the consultation.
In the pre-consultation period the patient’s
notes or records should be checked to raise
awareness of previous problems or any regular
treatments the patient is having or medication
the patient is taking (Chafer 2003). Attention
should be paid to comfort, privacy and the
creation of a safe environment. The possibility
of interruptions and being overheard can
discourage or prevent patients from telling their
story (Clark 1999, While 2002).
Before the patient arrives in the room the
practitioner should deal with, or at least
acknowledge, any negative feelings or stress.
Patients seek healthcare assistance for a variety
of reasons, including physical, psychological and
social reasons. Consultations can be stressful
and emotionally draining and, in a busy clinical
environment, it is easy to hang on to charged
emotions from a previous encounter (Clark 1999).
Starting a consultation in a distracted state of
mind can adversely affect performance and result

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in clinical errors (Chafer 2003). Taking a break or
speaking to a colleague between consultations can
help the practitioner refocus for the next
appointment (Clark 1999, Moulton 2007).
Time out 1
When preparing for a consultation
how do you attend to self-comfort
and putting aside feelings and
emotions? How do you prepare the
environment to ensure comfort,
privacy and safety are maintained for
patients?
The success of any consultation depends on how
well the patient and practitioner communicate
with each other. There is evidence to link the
quality of this communication to clinical
outcomes (Gask and Usherwood 2002).
Developing and maintaining rapport are central
to good communication and an effective
consultation. Rapport is the ability to be on the
same wavelength and to connect mentally and
emotionally with others, promoting trust and
mutual respect (Moulton 2007).
To build rapport, practitioners should begin
the consultation with a greeting, introduce
themselves and state their role. It is particularly
important to know and use the patient’s name
(Clark 1999). Making patients feel welcome by
attending to their comfort and using non-verbal
communication skills and gestures such as
smiling, eye contact and a handshake are
important (While 2002, Chafer 2003).
The physical distance between the clinician and
patient can have an impact on rapport. A balance
needs to be achieved between appearing
over-familiar by being too close to the patient and
appearing aloof by positioning oneself, for example,
behind a large desk (Clark 1999, Chafer 2003).
Time out 2
Spend some time observing
people around you, either at work
or socially. Take note of when you
think two people have a rapport.
What do you see that tells you this?
There are many different ways of starting a
consultation. Most practitioners start with a
question such as: ‘How can I help you?’ or ‘What
can I do for you?’ Most patients will come having
prepared or rehearsed what they are going to say.
Neighbour (1987) refers to this as a ‘gambit’.
52 october 1 :: vol 23 no 4 :: 2008
Sometimes gambits get overtaken by what is
known as a ‘curtain-raising’ phrase, a spontaneous,
unguarded remark that patients make on coming
into the room, something they had not planned to
say that is an eye-opener and provides valuable
clues to their inner world (Moulton 2007).
According to Moulton (2007) practitioners
who start their consultations with a question may
miss the opportunity for the curtain-raising
phrase, which may prevent patients from
disclosing what they had prepared and rehearsed
to say. An alternative approach at the beginning
of a consultation is to use words not phrased as a
question such as, ‘Hello, nice to see you, come
and sit down’. This approach, coupled with good
eye contact and using encouraging gestures such
as smiling and nodding, engages patients and
encourages them to start telling their story
(Moulton 2007).
In the early minutes of the consultation the
practitioner should leave as much space as possible
for the patient to talk without interruption.
Patients who are allowed to carry on talking until
they stop usually do so within two minutes and, by
this time, they have usually told the practitioner
everything that is relevant (Moulton 2007).
Doctors often interrupt to ask about the first
issue mentioned by the patient, yet this may not be
what is most concerning them. Once a practitioner
has interrupted, patients rarely introduce new
issues (Gask and Usherwood 2002). This can
result in failure to disclose significant concerns
(Simpson et al 1991).
Time out 3
Recall the most recent time you
were a patient in a consultation.
Who started the consultation?
Did it help or hinder the process?
Did you prepare a ‘gambit’ or use a
‘curtain raiser’?
Gathering information
The second section of the Calgary-Cambridge
guide is concerned with developing patients’
stories, gathering information that integrates
clinical content with an understanding of how
patients cope with their symptoms, and an
appreciation of concerns and ideas they may have
about their condition. Despite patients rehearsing
their story before the consultation, many still
need help to express themselves and provide a
competent clinical history (While 2002).
Taking a patient history is like playing
detective, ‘searching for clues, collecting
information without bias, yet staying on track to
solve the puzzle’ (Clark 1999). An accurate
history can provide 80% or more of the
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information required for diagnosis (Epstein et al
2008), therefore history taking is essential to the
consultation process. Active listening, which is
described as the most fundamental
communication skill (Duxbury 1999), is central to
obtaining a comprehensive history.
Time out 4
Define what active listening
means to you. Ask a friend or
colleague to start telling you what
he or she did on holiday. Use
the skills of active listening to get
more information.
Active listening encompasses verbal and
non-verbal behaviours. Egan (2007)
emphasises the non-verbal elements of active
listening in the SOLER framework, which
involves sitting Square on to the patient with
an Open position, Leaning slightly forward
with Eye contact in a Relaxed posture. The
verbal elements of active listening encompass
appropriate questioning techniques and
summarising and recalling the history back
to the patient to ensure that nothing is missed.
Use open questions initially as they cannot be
answered by a yes or no and they enable patients to
expand their story. For example, ‘Tell me more
about your chest pain’ encourages the patient to
tell the practitioner more. In contrast, closed
questions such as, ‘Is the chest pain severe?’, which
can be answered yes or no are useful in seeking
specific data that are required to gain a deeper
understanding of the patient’s problems.
Summarising the patient’s history and recalling
it back to him or her is important to ensure that
the practitioner has the correct information.
Summarising should not be a passive activity but
a dynamic process in which the practitioner and
patient construct a shared overview of the
problem. Summarising gives the patient an
opportunity to clarify details, make corrections
and add further contributions (Moulton 2007).
Asking the patient if there is anything else gives
him or her a final opportunity to add any
additional information (Lloyd and Craig 2007).
When talking to patients it is easy to be
side-tracked or omit important questions,
therefore it is helpful to use a history-taking
framework which gathers information in an
orderly way. The patient’s presenting problem
or difficulty, medical history, current health,
family history and psychosocial history should
be explored, and a review of systems – focused
questions about the health of all body systems –
undertaken. This review is a way of checking
that key information has not been missed
during history taking (Clark 1999).
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Presenting problem or difficulty The presenting
complaint provides a good starting point for
history taking as it is often considered the
patient’s most important concern. It is important
to explore sensitively patients’ ideas and concerns
about their symptoms and their expectations
from the consultation to promote patient-centred
consultations (Moulton 2007). Exploring
patients’ ideas about their symptoms involves
asking them what they think the problem is.
Their perception is especially important for the
explanation and planning stage of the
consultation. If a patient has different ideas from
the practitioner about the cause and management
of the symptoms, constructing an effective
management plan is likely to fail.
The patient’s particular concerns in relation
to the symptoms should also be explored. Most
patients do not admit their anxieties (Chafer
2003). Asking patients what they think the
problem is, encourages them to share their inner
feelings. Patients cannot be advised effectively or
reassured if the practitioner does not discover
what is really worrying them (Moulton 2007).
Finding out what patients think or hope the
practitioner is going to do is also important. It
can provide additional clues to the patient’s
underlying level of concern and provides
information about options to incorporate when
discussing symptom management.
Time out 5
How might you ask patients directly
for their ideas, expectations and
concerns? Choose a condition relevant
to your clinical area. Ask a colleague to
play the role of a patient with this condition
and try out phrases to discover his or her ideas,
concerns and expectations.
When taking a history, encourage patients to
describe their symptoms in the most expansive
manner. Several frameworks have been developed
to help with the process. The mnemonic PQRST
(Zator Estes 2002) is most useful in gathering
information about symptoms:

P = Provocation and palliation.

Q = Quality.

R = Region and radiation.

S = Severity.

T = Timing.
Provocation and palliation When taking a history,
explore what causes or exacerbates the patient’s
symptoms and if anything relieves them. This
information can provide important clues to help
with diagnostic decision making. For example,
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learning zone communication skills
without exploring provocation in a patient
complaining of a cough, one may miss the fact
that the symptoms coincided with starting the drug
captropil, which is an angiotensin-converting
enzyme inhibitor with a side-effect profile that
includes persistent dry cough.
Quality The quality of the symptoms is a
description of how they appear to the patient. The
words that patients use can be useful in making a
diagnosis. For example, crushing chest pain is a
good description of the pain of myocardial
infarction (Clark 1999).
Region and radiation It is important to establish
where the symptoms or pain are being
experienced and if they extend to other areas.
Exploring region and radiation can help to
develop a more comprehensive description of the
patient’s problem. For example, unless asked
about radiation a patient with pain in the
abdominal region may omit to disclose that the
pain has spread to the right iliac fossa, which is
indicative of appendicitis. Asking about radiation
can assist discovery of the real extent of the
problem (Clark 1999).
Severity A rating scale can be used in the
assessment of severity of pain or symptoms. A
numerical scale of 0-10 is most commonly used.
Timing The timing of symptoms is an important
factor in many disease processes. To generate a
clear picture of the problem it is useful to explore
when the symptoms started, timing during the
day, pattern and consistency and whether they are
continual or intermittent. For example, an
exploration of the timing of cough symptoms in a
child that reveals the problem persistently occurs
at night generates a picture of asthma.
Medical history Obtaining medical history is an
essential component of assessment and is
required to put the present illness into context.
Information should be sought about previous
illnesses, hospitalisations, operations and
accidents. Any relevant medical history should be
explored with the patient.
Current health Important topics to review in
relation to current health include habits such as
smoking and alcohol and drug use. In addition,
diet, sleep and preventive health measures such as
screening and immunisation should be reviewed.
Establish what drugs the patient may be taking
because the problem could be linked to this
medication. Drugs can cause harmful side effects
and patients can experience adverse drug
reactions and interactions. The practitioner
should enquire about prescription only
medicines, those bought over the counter and any
herbal or homeopathic remedies the patient is
54 october 1 :: vol 23 no 4 :: 2008
taking. Note should also be taken of any allergies.
Family history A comprehensive history should
also include a record of relevant family history.
The patient’s problem may be linked to hereditary
or genetic disease. Practitioners should enquire
about all the family members affected by such
diseases for at least two generations (Clark 1999).
Important diseases to ask about include
cardiovascular and respiratory problems, cancer,
diabetes, renal disease, allergies and mental
health problems (Clark 1999).
Psychosocial history Eliciting a psychosocial
history involves finding out about the patient’s
living situation, occupation and hobbies. In
addition, it entails exploring how connected
they are to others and their general feelings of
wellbeing. As with the other aspects of the history,
the information gathered may provide an
important indication of the patient’s diagnosis.
Review of systems A history is not complete
without a review of systems. The idea of the
review is to double check that any important
information has not been missed (Clark 1999).
The review is usually taken in a logical
‘head-to-toe’ sequence:

Head: the patient should be asked about any
headaches, dizziness, faintness or head injury.

Eyes: enquiries should be made about any
changes in vision or the presence of any
redness, irritation, watering or discharge.

Respiratory, including ear, nose and throat:
the patient should be asked about breathing
problems, wheeze, cough, sputum production
or coughing up blood. Any earache, sore throat
or hearing problems should be established.

Cardiac: the patient should be asked about
heart problems or palpitations. In addition,
enquiries should be made about raised blood
pressure or anaemia.

Gastrointestinal: any symptoms of heartburn,
indigestion, nausea, vomiting or flatulence
should be established. Enquiries should also
be made about any change in bowel movement
or rectal problems.

Sexual health: the practitioner should point
out that he or she is concerned about all aspects
of health and that people can have questions
about sexual health. This paves the way for
asking if the patient has any concerns in
relation to sexual health.

Musculoskeletal: enquiries should be made
about pain, stiffness or swelling of joints and
any muscular pain, cramp or loss of strength.

Neurological: patients should be asked if they
have noticed any numbness, tingling, tremors,
weakness or difficulty co-ordinating movement.
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A comprehensive history provides the basis for
the practitioner to problem solve through the
development of hypotheses. A hypothesis is a
provisional explanation of the patient’s problem.
Several hypotheses may be generated throughout
the consultation. These are supported or rejected
by gathering more detailed information, by
conducting a physical examination or ordering
further investigations (Crumbie 2005a). It is not
always possible to make an immediate diagnosis
and, in some cases, it is necessary to cope with
uncertainty until test results or other information
becomes available (Crumbie 2005a).
Time out 6
Choose a condition that patients
present with in your clinical area.
List the basic areas of information
or data that you need to discuss to
make an accurate assessment of the
condition. Ask a colleague to play the role
of a patient with the condition and take a
history using the areas of information that
you have listed.
Explanation and planning
Stage three of the Calgary-Cambridge guide is
concerned with explanation and planning. The
guide emphasises a shared approach to planning
and discussing treatment options between patient
and practitioner (Munson 2007). In addition, it
addresses how to provide the correct amount and
type of information for patients and methods of
aiding accurate recall and understanding.
Partnership with patients involves keeping
them fully informed about their diagnosis and
treatment options. However, some patients may
not wish to be actively involved in decision-
making or in the management of their condition.
This requires the practitioner to adopt a different
approach to each situation (Crumbie 2005b).
Providing the correct type and amount of
information entails actively finding out what
patients already know and have experience of and
what and how much more they want to know.
This helps the practitioner plan what he or she
needs to cover, what can be left out and any
additional information required (Chafer 2003).
If information is to be remembered and
understood, it must be given to patients in a form
that is clear and unambiguous. Use concise, easily
understood language and explain jargon.
Categorising and signposting information can
make it more memorable for patients (Chafer
2003). This involves dividing the topic to be
discussed into discrete aspects of information.
Using the mnemonic DCEPT can be helpful in
preparing the patient and practitioner to think in a
logical sequence under identifiable headings:
NURSING STANDARD

D = Diagnosis.

C = Cause.

E = Expected course.

P = Prognosis and seriousness.

T = Treatment.
‘Chunking and checking’ involves delivering
information in small quantities and then stopping
to check the patient has taken it in before
moving on. This is an important skill in aiding
understanding and recall. Patients hear and take in
information more effectively when it is delivered
in small amounts and their understanding is
checked before moving on. When checking
understanding use phrases that do not belittle
patients but convey that the clinician cares about
their understanding (Moulton 2007). Finally,
repetition by the clinician to summarise key areas
is an important skill that increases patient recall.
Time out 7
List the essential information
you consider you should attempt
to get across to a patient with a
condition relevant to your area of
practice. Practise giving this information
to a colleague and ask him or her for feedback.
Also try categorising, signposting, chunking,
checking and summarising the information.
Closing the session
The final phase of the Calgary-Cambridge guide
is concerned with closing the consultation, which
involves the important functions of ‘safety netting’
and final checking. Safety netting sets out
contingency plans in the eventuality that
something goes wrong (Chafer 2003). This
empowers patients and protects practitioners.
Safety netting involves reiterating to the patient
what you think is wrong and explaining how
to recognise unexpected developments either
through persistence or recurrence of symptoms
or their duration or timing (Chafer 2003). In
addition, explaining to patients how or from
whom they should seek further help is important.
While safety netting is a key tool in all
consultations, it is essential in any encounter
where one has limited information. This includes
telephone consultations where there are no visual
clues, out-of-hours consultations where one has
no previous knowledge of the patient, or
consultations where the practitioner is tired
or not up to his or her usual form.
As the consultation is drawing to a close there
is a final chance to ask if there is anything else the
patient would like to discuss. Moulton (2007)
refers to this as a ‘catch all’ and describes it as being
october 1 :: vol 23 no 4 :: 2008 55
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underpin problem solving and clinical decision

learning zone communication skills
both beneficial and problematic. It is beneficial
because it sometimes uncovers significant
problems. However good the practitioner’s skills,
there are some patients who save the ‘real’ problem
to the end of the consultation. This can be
problematic because asking if there is anything else
the patient wishes to discuss requires time and
willingness to deal with whatever the patient says,
even if all one does is negotiate another
consultation (Moulton 2007).
Time out 8
Reflect on your current pattern of
safety netting. How often do you
use a safety net? Is it adequate?
Think about how you end your
consultations and consider if this could
be improved and whether you need to do
anything differently.
Conclusion
Skills in consulting patients and history taking are
becoming increasingly important in nursing as
practitioners expand the boundaries of their
practice and work more autonomously. As
practitioners must accept responsibility for
autonomous decision making, it is essential that
nurses develop effective consultation skills to
making. The Calgary-Cambridge consultation
guide addresses the skills required for an effective
consultation and provides a framework that
promotes structure and direction.
The guide addresses the importance of
preparing for the consultation and developing a
rapport with the patient. This promotes an
atmosphere of trust and gives patients
confidence to tell their story. The guide also
emphasises the importance of taking an accurate
and complete biomedical history, coupled with
an exploration of the patient’s perspective that
encompasses their ideas, concerns and
expectations. Without both perspectives, a
shared understanding between patient and
practitioner may not be achieved. This can
adversely affect management and concordance
with treatment. The guide emphasises the
importance of providing the right amount and
type of information to individual patients, and
explores the skills required to give information
effectively. Finally, it emphasises completing the
important function of safety netting when
drawing the consultation to a close NS
Time out 9
Now that you have completed
the article, you might like to write
a practice profile. Guidelines to help
you are on page 60.

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