{"title":"如何全面了解患者病史。","authors":"Sarah Butler","doi":"10.7748/en.2024.e2209","DOIUrl":null,"url":null,"abstract":"<p><strong>Rationale and key points: </strong>A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure. • History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment. • Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity. • By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when taking a patient history. • How you could use this information to educate nursing students or colleagues on taking a patient history.</p>","PeriodicalId":94315,"journal":{"name":"Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association","volume":" ","pages":"16-20"},"PeriodicalIF":0.0000,"publicationDate":"2025-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"How to take a comprehensive patient history.\",\"authors\":\"Sarah Butler\",\"doi\":\"10.7748/en.2024.e2209\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Rationale and key points: </strong>A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure. • History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment. • Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity. • By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when taking a patient history. • How you could use this information to educate nursing students or colleagues on taking a patient history.</p>\",\"PeriodicalId\":94315,\"journal\":{\"name\":\"Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association\",\"volume\":\" \",\"pages\":\"16-20\"},\"PeriodicalIF\":0.0000,\"publicationDate\":\"2025-03-04\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"https://doi.org/10.7748/en.2024.e2209\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2024/7/30 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"\",\"JCRName\":\"\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.7748/en.2024.e2209","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/7/30 0:00:00","PubModel":"Epub","JCR":"","JCRName":"","Score":null,"Total":0}
Rationale and key points: A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure. • History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment. • Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity. • By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when taking a patient history. • How you could use this information to educate nursing students or colleagues on taking a patient history.