This research paper reviews the importance of patient history taking and physical in diagnosis. For effective history taking, there should be some communication between the patient and doctor. This ensures that the doctor captures all necessary steps of history taking. With good communication, the patient can explain his condition and answer the doctor’s questions accordingly. This way, it becomes much easier to identify the patient’s problem. Nursing consultation skills are, therefore, crucial in patient history taking. Effective communication skills reveal the patient’s ideas, concerns, and expectations as well as any accompanying diagnosis. Sometimes, history taking is enough for diagnosis. History taking is more useful with the patient’s perspective.
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NURSING CONSULTATION DURING PATIENT HISTORY TAKING
This section discusses the nursing consultation skills required to obtain the patient’s true story. These skills go beyond the regular questions asked by doctors. Doctors need to be aware of the aspects surrounding consultations and history taking, such as the setting. Patient history taking should happen in an environment where patients feels confident to share personal and private information. This facilitates establishing rapport. The room should allow for good eye contact and easy access to notes regarding the patient’s condition. Doctors should go through all the steps of history taking by giving patients the chance to explain their pre-constructed narratives first. This approach affords a better chance of obtaining precise details of their experience of illness.
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IMPORTANCE OF THE HISTORY, PROCEDURE, AND STEPS OF HISTORY TAKING
The steps of history taking begin with introductions. Here, doctors ask patients for permission to take notes about the condition. After that, the patient explains their complaint, and doctors ask questions to gain more information about the particular complaint. Since this procedure involves communication, nursing consultation skills are crucial. This helps doctors and nurses to gather accurate information on the patients’patients’ past medical history and drug history, including information about patient allergies. When conducting patient history taking, medical professionals may require more details concerning family histories, such as cardiac history and the social history of the patient. Social history provides information about the history of drug abuse and other details.
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