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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
Chapter 2 Health assessment
skill 2-1
Taking a patient history
Goal:
An accurate and concise patient history is obtained.
1. Identify the patient and place an ID band on the patient.
2. Review any documentation that has accompanied
the patient (e.g. doctor’s letter, preadmission clinic
information).
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
admission forms.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), if indicated.
8. Ensure that patient privacy is maintained and the patient
is comfortable. Ensure that interruptions are minimal.
9. Assess the situation for any potential danger to you or the
patient.
10. Approach the patient, observing the patient’s response,
airway, breathing and circulation, and conscious state.
(Primary survey)
11. Invite significant others to be present for the history
taking, if appropriate.
12. Commence the patient interview using appropriate styles
of questioning and non-verbal communication and
focusing techniques.
13. Collect bibliographical data.
14. Collect data regarding the patient’s physical symptoms.
15. Collect data regarding the patient’s past health history.
16. Collect data regarding the patient’s family history.
17. Collect data regarding the patient’s health and lifestyle
practices.
18. Ensure all data are documented.
19. Clarify the important information collected and
paraphrase to confirm understanding.
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