Taking a nursing history is a foundational skill for healthcare providers. It involves gathering details about a patient’s health, lifestyle, and concerns to create a personalized care plan. This guide breaks the process into clear, actionable steps. Follow these methods to collect accurate information, build trust with patients, and improve care outcomes.
1. Prepare Your Environment and Approach
Create a private, comfortable space.
Patients share sensitive information more openly in quiet, distraction-free settings. Close doors, adjust lighting, and ensure seating allows for eye contact.
Introduce yourself clearly.
State your name, role, and purpose. Say, “Hi, I’m [Name], a nurse caring for you today. I’d like to ask questions about your health to better understand your needs.”
Explain confidentiality.
Assure patients their information stays private. Say, “Everything you share is confidential and used only for your care.”
Use open body language.
Sit at eye level, avoid crossed arms, and nod to show engagement. Small gestures build rapport.
2. Collect Basic Demographic Information
Start with straightforward facts to ease the patient into the conversation. Record:
- Full name
- Age and date of birth
- Gender identity
- Contact details (address, phone)
- Emergency contact
- Primary care provider
- Insurance information
Example:
“Let’s start with basic details. Can you confirm your full name and date of birth?”
3. Identify the Chief Complaint
Ask the patient to describe their main concern in their own words. Use open-ended questions:
- “What brought you in today?”
- “What’s been bothering you most?”
Document the chief complaint verbatim.
If a patient says, “My chest feels tight,” write exactly that—avoid paraphrasing.
4. Explore the History of Present Illness (HPI)
Dive deeper into the chief complaint using the OLD CARTS framework:
- Onset: “When did this start?”
- Location: “Where do you feel it?”
- Duration: “Is it constant or comes and goes?”
- Characteristics: “How would you describe the pain?”
- Aggravating/Relieving factors: “Does anything make it worse or better?”
- Timing: “Does it happen at specific times?”
- Severity: “Rate your discomfort from 1 to 10.”
Example:
A patient reports abdominal pain. Ask, “Was the pain sudden or gradual? Does it spread anywhere?”
5. Review Past Medical History
Gather details about prior health issues. Ask:
- “Have you had surgeries or hospitalizations?”
- “Do you have chronic conditions like diabetes or asthma?”
- “Are you allergic to medications, foods, or materials?”
- “What medications do you take? Include doses and frequency.”
Pro tip: Verify medication lists with a pill bottle or pharmacy records for accuracy.
6. Discuss Family Medical History
Identify genetic or environmental health risks. Ask:
- “Do parents, siblings, or children have conditions like heart disease or cancer?”
- “Has anyone had similar symptoms?”
Example:
“Has anyone in your family been diagnosed with high blood pressure?”
7. Investigate Social History
Understand the patient’s lifestyle and environment. Cover:
- Occupation: “What type of work do you do?”
- Diet/Exercise: “Describe a typical day of meals and activity.”
- Substance Use: “Do you smoke, drink alcohol, or use other substances?”
- Living Situation: “Who do you live with? Any pets?”
- Mental Health: “How has your mood been lately?”
Be nonjudgmental.
Frame questions neutrally: “How many cigarettes do you smoke daily?” instead of “You don’t smoke, right?”
8. Conduct a Review of Systems (ROS)
Perform a head-to-toe assessment by asking about symptoms in each body system:
- Head: Headaches, dizziness
- Eyes: Vision changes, dryness
- Respiratory: Cough, shortness of breath
- Cardiac: Chest pain, palpitations
- Gastrointestinal: Nausea, bowel habits
- Neurological: Numbness, memory issues
Use closed-ended questions here:
“Have you had recent weight loss?” (Yes/No)
9. Validate and Clarify Information
Summarize key points to ensure accuracy. Say:
- “Let me confirm: Your back pain started two weeks ago after lifting a heavy box. It’s a sharp pain, rated 7/10, and worsens when standing. Correct?”
Invite corrections:
“Did I miss anything important?”
10. Document Clearly and Thoroughly
Record findings in the patient’s chart using objective language. Avoid opinions like “patient seems anxious.” Instead, write “patient reports difficulty sleeping due to worry.”
Prioritize readability:
Use bullet points, headings, and abbreviations like “SOB” (shortness of breath) if your facility allows.
11. Adapt to Special Situations
For pediatric patients: Ask caregivers for details but engage the child with age-appropriate questions.
For critically ill patients: Focus on immediate concerns first; gather full history later.
For language barriers: Use certified interpreters, not family members, to ensure accuracy.
12. Maintain Cultural Sensitivity
Respect beliefs and traditions. Ask:
- “Are there cultural practices I should consider in your care?”
- “Do you prefer a same-gender provider?”
Common Mistakes to Avoid
- Leading questions: “You don’t smoke, right?” → “Do you use tobacco?”
- Interrupting: Let patients finish before asking follow-ups.
- Assuming: Don’t presume marital status, sexual orientation, or health literacy.
Why Nursing Histories Matter
A thorough history helps:
- Identify undiagnosed conditions
- Prevent medication errors
- Tailor patient education
- Build therapeutic relationships
Practice Makes Progress
Improve your skills by:
- Shadowing experienced nurses
- Role-playing with peers
- Reviewing sample case studies
Final Thoughts
Taking a nursing history is both science and art. It requires attention to detail, empathy, and active listening. By mastering this process, you’ll deliver safer, more effective care while empowering patients to share their stories.
