Tips for Taking Patient’s History in Shadow Health

Tips for Taking Patient’s History in Shadow Health

Developing a comprehensive health history is anchored in some of the nursing theories. Therefore, a nurse practitioner must conduct a history-taking exercise to facilitate patient-centered, safe, and quality care. Interviewing the patient allows you to collect subjective data. And as you interview, ensure that you take notes and review the objective data on the patient charts, electronic health records, and other documentation. Just like in real-life situations, here is how to proceed with history-taking activity in shadow Health:

1. Introduce yourself to the patient and identify them as you seek consent to speak to them. If you are taking any notes, ask for the patient’s permission. Take as much patient biodata as possible, including their marital status, occupation, age, gender, name, etc. Check who is accompanying them during the assessment.
2. Focus on the chief complaint by asking the client what brings them to the Shadow Health general clinic. Subjective data from the patient will help you determine their chief complaint.
3. Try to gain as much information as you can about the specific complaint. If you are examining pain, you can use the SOCRATES question approach outlined below:

• Site: Where exactly is the pain?
• Onset: When did it start? Was it constant/intermittent, gradual/ sudden?
• Character: What is the pain like, e.g., sharp, burning, tight?
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain, e.g., sweating or vomiting?
• Time course: Does it follow any time pattern? How long did it last?
• Exacerbating/relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain? Consider using the 1-10 scale.

4. Check on the past medical history of the patient. Check if the patient has missed any immunizations, had lifestyle issues, or had illnesses in the past.
5. Collect data about drug history. Inquire from the patient about the medications they are taking, including dosage and how often they are taking them. Also, find out if they have any allergies.
6. Ask about the family history of the patient. For instance, ask for a history of cancers, diabetes, obesity, or cardiac issues. Ensure that you inquire about any genetic conditions within the family.
7. Ask questions about the patient's social history, including their background, use of illegal substances, whom they live with, their social life, etc.
8. Gather and review information about the main systems, including the cardiovascular, respiratory, GI, neurological, Genitourinary or renal systems, musculoskeletal, and psychiatry.
9. Summarize the history by reviewing what the patient has told you by repeating the important points to the patient so that they can correct you or make corrections if there are misunderstandings.
10. Conclude by asking if the patient has questions.

Good patient history is integral when writing a SOAP note. And comprehensive patient-centered care is permanently fused with a physical examination. Let’s look at some tips to use during physical examination.

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