ADMISSION and DISCHARGE

LEARNING OBJECTIVES:
1. Apply principles, theories and guidelines on how to admit and discharge patients following the
protocols.
2. Recognize nursing responsibilities in relation to health records
3. Develop skill on how to record pertinent data and report relevant patient information accurately
and effectively.
4. Understand the accuracy of making a health report
5. Contribute in the maintenance of the health of the mother as well as the wellbeing of the fetus
during antepartal assessment
6. Apply the proper technique of doing LeopoldsManeuver and do correct computations for
AOG/EDD
7. Develop effective communication using culturally – appropriate language during interviews and
history taking

DEFINITION:
 ADMISSION is the act or process of accepting someone into a hospital, clinic, or other treatment
facility for patient care and management
 The stay of a sick person in a health facility for the purpose of observation, investigation and
treatment that can only be performed in the hospital setting.
TYPES OF HOSPITAL ADMISSION:
1. PLANNED ADMISSION
 Planned admission is one in which the patient and the family had a prearranged date for
treatment and knew that an admission to the hospital would follow
 The specialist will send the patient for further tests to assess the health issue, before
deciding what kind of treatment is required.
 Request for admission by a medical practitioner/ specialist
 At this stage, the client will also be told how long they will have to wait for treatment.
 Stay in hospital will depend on the kind of treatment needed
2. UNPLANNED (URGENT) ADMISSION
 The condition is unexpected and needs urgent but not immediate treatment
 The client needs significant attention based on seriousness of their condition
- this is done through a process known as ‘triage’
TRIAGE
 is a medical process of sorting out patients according to their need for care
 Patients with the most severe health problem receive immediate treatment.

DIFFERENT STEPS IN TRIAGE:

STEP 1 – ASSESSMENT
A registered nurse will take the medical history and perform a brief examination of presented
symptoms
STEP 2 – REGISTRATION
Triage staff gather information patient record and obtain consent for treatment.
Both are necessary to order diagnostic tests to enable the physician determine the best treatment
option.
STEP 3 – TREATMENT
 Depending on patient condition, a registered nurse may start an intravenous (IV) line
 A nurse or technician may also take blood or urine samples, or they may send for an X-ray or
other imaging test before a physician sees the client.
STEP 4 – RE EVALUATION
An Emergency physician or mid-level practitioner will re- evaluate condition after they receive
test results because the results may give them additional insight into the type of treatment
needed.
 After re evaluation, the attending physician determines whether the patient should be admitted
to the hospital or treated and sent home
STEP 5 – DISCHARGE
All patients receive written home-care instructions to follow when discharged.
The instructions describe how you can safely care for wound or illness, directions prescribed
medications and recommendations for follow-up medical care. 

FOUR CATEGORIES IN TRIAGE:

1. Immediate (red tag): casualties with life threatening but treatable injuries requiring immediate
medical attention are assigned a red tag
2. Urgent (orange or yellow tag): casualties with serious injuries, but able to wait a short time for
treatment are assigned an orange tag
3. Delayed (green tag): casualties who can wait hours to days for treatment are assigned a green
tag.(i.e. ‘minor’ casualties)
4. Dead (white or black tag): casualties who are dead or not expected to live because of the
severity of their injuries and the limited resources available.
These casualties are assigned either a white or black tag

OTHER TYPE OF ADMISSION:

EMERGENCY ADMISSION
 These patients are usually admitted via the Emergency Department requiring immediate life-
saving treatment
 May be a direct admission to an Intensive Care Unit, Burns Unit or other OR
Example: cardiac and respiratory emergency

TYPES OF PATIENT ADMISSION

1. Inpatient-one has to stay in the hospital for one night or more for tests, medical treatment or
undergo surgical procedure
2. Day patient-(scheduled) hospital bed is given for tests or surgery, but will not stay overnight.
Example are minor surgery, dialysis or chemotherapy
3. Outpatient-patient who enters the hospital, doesn’t need to be admitted
COVID-19 GUIDANCE FOR HEALTHCARE FACILITIES FOR ADMISSIONS
 Ensure rapid safe triage and isolation of patients with symptoms of suspected COVID-19 or other
respiratory infection (e.g., fever, cough).
 Prioritize triage of patients with respiratory symptoms.
 Triage personnel should have a supply of facemasks and put on PPE and tissues for patients with
symptoms of respiratory infection.
 Ensure that, at the time of patient check-in, all patients are asked about the presence of
symptoms of a respiratory infection and history of travel to areas experiencing transmission of
COVID-19 or contact with possible COVID-19 patients.
 HCP must take care not to touch their eye protection and respirator or facemask. Eye
protection and the respirator or facemask should be removed, and hand hygiene performed if
they become damaged or soiled and when leaving the unit.
 HCP should strictly follow basic infection control practices between patients (e.g., hand hygiene,
cleaning and disinfecting shared equipment)

COMMON HEALTHCARE FACILITIES IN THE PHILIPPINES:

1. Hospitals, ambulatory medical clinics and primary health care facilities
(Barangay Health Centers, Birthing Centers/Lying Ins)
HOSPITAL-are usually designed to provide both inpatient and outpatient care. 
2. Ambulatory Medical Clinics are usually designed to provide only outpatient care
3. Primary Health Care services are offered by local government units (LGU) and provided by both
the public and private sector
These health care services are provided by barangay health workers, volunteer community health
workers, midwives, doctors, nurses, medical technologists and nutritionists.
FOCUS of THE PRIMARY HEALTH CARE CENTERS is on PREVENTIVE MEDICINE SUCH AS:
1. Health and nutrition advice.
2. Family planning services
3. Prenatal and postpartum care
4. Tuberculosis TB Program
5. Under 1-Year-Old Children
6. Laboratory services.
Health professionals in the private sector provide primary health care in private clinics, often located
within hospitals, and group practice clinics or polyclinics.
All consultations and treatments must be paid for.

THE DIFFERENT TYPES OF HOSPITALS BASED ON THE CLASSIFICATION OF PH DEPARTMENT OF HEALTH

1. GENERAL OR SPECIAL
 General –admit all types of medical and surgical cases, and they concentrate on patients
with acute illnesses needing relatively short-term care.
Example: Feu-NRMF Hospital, UST Hospital, St. Luke’s Hospital
 Special– primarily engaged in the provision of specific clinical care and management
Example: National Kidney Institute, Philippine Heart Center, Lung Center of the Philippines,
Philippine Orthopedic Center, National Mental Hospital
 2. ACCORDING TO OWNERSHIP:
 Private or government-owned
 Private Hospital- owned and governed by a person or many people who are managing the
whole finances on their own
Patients buy their own medicines
Fees of a private hospital are higher
 Public Hospital- completely and entirely run on government’s funding and money.
Medicines are based on the government budget.
Lower fees
3. AS TO SERVICE CAPABILITY
 LEVEL l-cater to patients who need minor care and supervision.
- the most basic, hospitals under this bracket don’t require intensive care units
-non-contrast radiographic examinations
 LEVEL 2-contains all the elements of Level 1, as well as additional facilities like an ICU for
critically ill patients and specialist doctors for gynecology and pediatric services
-general anesthesia& with non-contrast and contrast radiographic examinations
 LEVEL 3- provides high-level specialty intervention like physical rehabilitation or dialysis
treatment
 LEVEL 4-teaching and training hospital (with at least one Accredited Residency Training
Program for Physicians)
(tertiary clinical laboratory, third level radiology, pharmacy)

NURSING RESPONSIBILITIES OF ADMITTING NURSE

1. Accomplishment of admission form/ Health Record
 Doctor's Admission Order Sheet, Patient Information Sheet, Item Numbers – Registration,
Case #s, Details of medical history
2. Informed Consent
3. Assessment/Monitor vital signs
 Complete workup and vital signs to provide the staff with a baseline from the time the
patient entered the hospital.
 Set up the initial treatment protocols.
4. Initiating transfer of patient the Assigned Unit
 Inform the area of the admission.
 Help the patient get settled in the room by facilitating the transfer to the area assigned.
5. Patient Orientation / Significant Others
 Equipment/ Instruments
 Use of call system
 Treatment Schedule
 Visitor timings
 Department policy rules and regulations
 Care of patient valuables
 Initiate fall precautions as dictated by institutional policy
6. Coordinate with the Attending Physician
 Carry out initial orders
DISCHARGE PLANNING
 As transitional care, discharge planning begins when one is admitted to the hospital
 Prepares the client and his family so they don’t have to make a rushed decision about what
happens after they leave the hospital.
 Ensures them to have services and support to meet their needs during their recovery
HOSPITAL DISCHARGE
 The point of relieving a person from hospital setting who is admitted as inpatient from the
hospital
 Formal termination of patient service by attending doctor when treatment is over.

PATIENT EDUCATION AND SUPPORT DURING DISCHARGE

 Ensure that patients are able to understand their health, illnesses, medications, and treatments
to the best of their ability.

Discharge Process using METHODS

M-EDICATION
o Lanoxin 0.25mg/ once a day
E-XERCISE
o Take breaks if you feel tired. Do not over exert.
T-REATMENT
o e.g. Apply ointment to affected area
o Change dressing aseptically once daily
H-EALTH TEACHINGS
o Lanoxin is best to be taken without food
o Monitor apical pulse for 1 full min before administering. Withhold dose and notify
health care professional if pulse rate is less than 60bpm
O-WHAT TO OBSERVE/ OPD
o Increasing shortness of breath and reduced tolerance of activity
o Follow up in RM. 204 of Marian Bldg. at 2pm. with Dra. Cruz
D-IET
o Low salt low fat diet-(limit salty foods, cut down on saturated fats, eat more fresh fruits
and vegetables )
S-PIRITUALITY/ SEXUAL ACTIVITY
o Ensure sense of hope and positivity
o Check with your doctor about when you can resume sexual activity. 

TYPES OF HOSPITAL DISCHARGE

1. PLANNED-patient completes the initial and actual management in the hospital
2. TRANSFER- inter hospital or another facility for change in level of care
3. REFERRAL-involves sending the patient to another physician for ongoing management of a
specific problem but still continue seeing the original physician for coordination of total care
4. LAMA-patient leaves the hospital against medical advice for personal reasons
5. ABSCOND-patient leaves the hospital without notifying the staffs and other hospital personnel
WHAT INFORMATION IS PROVIDED BY MEMBERS OF THE HEALTHCARE TEAM DURING THE DISCHARGE
PROCESS
1. Client’s medical condition at the time of discharge
2. What kinds of follow-up care is needed, such as physical therapy
3. What medications to take, including why, when, and how to take them, and possible side effects
to watch for
4. Instructions on food and drink, exercise, and activities to avoid
5. What to expect at the new facility, if the patient is not going home
RECORDING AND REPORTING
NURSING RECORDS AND REPORTS
(medical record, health record, and medical chart)
 HEALTH RECORD is the systematic documentation of a single patient’s medical history and care
across time.
The medical record includes a variety of types of "notes" entered over time by health
care professionals, recording observations and administration of drugs and therapies,
medication orders, test results, x-rays reports, etc.
 REPORTS are oral or written exchanges of information shared between caregivers in a number
of ways
It is the summary of activities or observations seen, performed or heard

TYPES OF NURSING REPORT

1. Change of Shift Reports-
 A report given by a primary nurse to the nurse who assumes responsibility for continuing
care of the patient. The change of shift report might be given in written form or orally.
 It provides basic identifying information such as patient condition,
current appraisal of each patients’ health status, current order by the
physician, changes of medication, intravenous fluids, diet, activity level.
 Summary of each newly admitted patient.
 Report on patients who have been transferred or discharged.
2. Telephone Reports
 Telephones can link healthcare professionals immediately and enable nurses to receive and
give critical information about patients in a timely fashion.
 Report the patients’ current vital signs and clinical manifestation investigation etc.
3. Incident Reports
 It is a tool used by heath agencies to document the occurrence of anything out of the
ordinary that results in harm to a patient, employee or visitor

IMPORTANCE OF RECORDS AND REPORTS:

FOR PATIENTS:
 Legal evidence
 It avoids duplication of treatment measures
 It avoids duplication of diagnostic and procedural measures
 It will assist in continuity of patient care
 It helps in health insurance of the patient
FOR DOCTOR:
 Legal protection of hospital
  Evaluate medical care given by doctor 
 Evaluate performance of individual doctors
 It also assist in planning and justification of resources
 FOR PUBLIC HEALTH
 Shows health problem in the family and other factors that affects health
 Provide information of vital statistics like mortality rate, morbidity rate, infant death rate etc.
 IN EDUCATION AND RESEARCH
 Forms basis of clinical research
 Aids in formal education of students and staff
 Reliable source of material for advancement in medical science.
PURPOSE OF RECORDS
1. Supply data that are essential for program planning and evaluation
2. Provide the practitioner with data required for the application of professional services for the
improvement of family’s health
3. Tools of communication between health workers, the family, & other development personnel
4. Help in the research for improvement of nursing care
5. Records from and on behalf of medical patients is a critical component of healthcare,
particularly when that data needs to be analyzed to provide the best and most proper care.
6. It is a written and legal recording of the interventions that concern the patient and it includes a
sequence of processes.
7. It is established with the personal record of the patient, which constitutes a base of information
on the situation of his health.

PURPOSES OF KEEPING RECORDS

 Communication
 Education
 Assessment
 Documentation of continuity and justification of case
 Research
 Auditing
 Legal documentation
 Individual case study

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

1. Keep under safe custody of nurses
2. No individual sheet should be separated
3. Not accessible to patients and visitors
4. Strangers is not permitted to read the record
5. Records are not handed over to the legal advisors without written permission of the
administration
6. Handed carefully
7. The patient has a right to inspect and copy the record after being discharged

NURSE CHARTING-20 PRINCIPLES COVERED:

1. Don’t erase what is recorded
2. Record all relevant information
3. Don’t write critical comments ()
 4. Don’t leave white space!
5. Record in black ink only
6. Clarify orders and treatment
7. Chart your own nursing process
8. Don’t use ambiguous statements-vague, unclear
(e.g., “the patient's vision appears blurred” or “the patient's vision appears to be improving”)
9. Only use approved abbreviations
10. Date/time/sign
11. Write legibly
12. Use ‘late entries’ notation
13. Don’t write in anticipation
14. Follow organization policies
15. Record telephone calls
16. Complete action and outcomes- “If you don’t chart it, it didn’t happen.”
17. Co-signing-jointly signed & endorsed
18. Use 24-hour clock-military time chart
19. Monitoring
20. Confidentiality/Security

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

1. 1.Failure to record makes a nurse guilty of negligence
2. 2.Medical record must be accurate to provide a sound basis for care planning
3. 3.Errors in nursing charting must be corrected promptly in a manner that leaves no doubts
about the facts
4. 4.In reporting information about criminal acts obtained during patient care, the nurse must
reveal such information only to the police, because it is considered a privileged communication
PRINCIPLES OF RECORD WRITING
1. Nurses should develop their own method of expression and form in record writing
2. Records should be written clearly & appropriately
3. Records should contain facts based on observation, conversation and action

TOOLS FOR COMMUNITY ASSESSMENT

1. Health records and reports
2. The Field Health Service Information System (FHSIS)
 the official recording and reporting system of the Department of Health
 used by the National Statistical Coordination Board to generate health statistics.

RECORDING TOOLS in the COMMUNITY

1. Individual Treatment Record (ITR) – is the building block of the FHSIS.
 The record contains the date, name, address of patient, presenting symptoms or complaint
of the patient on consultation and the diagnosis, treatment and date of treatment
2. Target Client Lists (TCLs) – are the second building block of the FHSIS.

THE FOLLOWING ARE THE TCL’S MAINTAINED IN HEALTH CENTERS

 TCL for Prenatal Care
 TCL for Postpartum Care
 TCL for Under 1-Year-Old Children
  TCL for Family Planning
 TCL for Sick Children
 National Tuberculosis Program TB register
 National Leprosy Control Program Central Registration Form

THE REPORTING FORMS

 MONTHLY FORM – are regularly prepared by the midwife and submitted to the nurse, who then
uses the data to prepare the Quarterly Forms.
 PROGRAM REPORT (M1) contains indicators categorized as maternal care, child care, family
planning, and disease control. The midwife copies the data from the Summary Table.
 MORBIDITY REPORT (M2) contains a list of all cases of disease by age and sex

ANNUAL FORMS
 ANNUAL FORM 1 (A-1) is prepared by the nurse and is the report of the RHU or health center. It
contains demographic and environmental data, and data on natality and mortality for the entire
year.
 ANNUAL FORM 2 (A-2), prepared by the nurse, is a yearly morbidity report by age and sex.
 ANNUAL FORM 3 (A-3), also prepared by the nurse, is the yearly report of all deaths (mortality)
by age and sex.
QUARTERLY FORMS are usually prepared by the nurse. There should only be one Quarterly form for the
municipality/city. Quarterly forms are submitted to the Provincial Health Office.

 PROGRAM REPORT (Q1) contains the 3-month total of indicators categorized as maternal care,
family planning, child care, dental health and disease control.
 MORBIDITY REPORT (Q2) is a 3-month consolidation of Morbidity Report (M2
SUMMARY TABLE

A 12-column table in which columns correspond to the 12 months of the year and is updated on
a monthly basis and has two components:
HEALTH PROGRAM ACCOMPLISHMENT- provides the midwife with a tool for assessment of
accomplishments and a ready source of reports.

MORBIDITY/DISEASES -gives information trend of diseases and serves as a source for the 10 leading
causes of morbidity in the municipality

The Monthly Consolidation Table (MCT) is accomplished by the nurse based on the summary
table.
- It serves as the source of document for the Quarterly form and the Output Table of the RHU
or health center
Multidisciplinary Patient and Family Education Record

Three PERIODS OF PREGNANCY

 ANTEPARTUM- time period before childbirth
 INTRAPARTUM-period from the onset of true labor through the delivery of the placenta
 POST –PARTUM timeperiod after childbirth

"ANTEPARTUM“& ASSESSMENT
  Used to denote the period between the 24th/26th week of gestational age until birth
 Antepartum assessment are part of the routine prenatal care to find conditions that may
increase the risk of complications for the mother and fetus (Eisenberg, Murkoff, & Hathaway,
1996). These can include blood and urine analyses and screening and diagnostic tests for birth
defects.
 Antepartum fetal assessment utilizes various techniques to assess fetal health and well-being in
pregnancies that are at increased risk of fetal death due to preexisting maternal conditions
(chronic hypertension) or pregnancy-related complications (fetal growth restriction

ANTEPARTUM (Antenatal care)

 Time period before childbirth
 Prepare women for delivery and understand warning signs during pregnancy and childbirth.

1. It can be a source of micronutrient supplementation:

-Iron(iron deficiency anemia)
-Folic acid 1 tablet 200 mg daily (neural tube defect)
-Iodine 2 caps taken as single dose increased maternal thyroid hormone production( increased
renal iodine losses and transfer of iodine to the fetus.)
 Maternal iodine deficiency ( hypothyroidism) during pregnancy have adverse effects on
the neurodevelopment of offspring:
 -cretinism in cases of severe iodine deficiency
 -defects in cognitive and motor development in cases of mild iodine deficiency.
1. Treatment of hypertension to prevent eclampsia
2. Immunization against tetanus diphtheria
3. HIV and Hepa B testing
4. Provide pregnant women with medications in areas where malaria is endemic

TRIMESTERS.
 Pregnancy is divided into three trimesters.
 A 'normal,' full-term pregnancy is 40 weeks and can range from 38 to 40 weeks.
 Each trimester lasts between 12 and 14 weeks, or about 3 months.
 Each trimester comes with its own specific hormonal and physiological changes

PRENATAL CHECK-UP
 First trimester begins on the first day of the last period and lasts until the end of week 12( five
or six weeks pregnant)
 Initial Prenatal Physical Exam:
o Vital signs
o Height and weight measurement
o Fundic height measurement
o Leopolds Maneuver
 

AOG COMPUTATION
AGE OF GESTATION (AOG)
  Age of the fetus in weeks
 -e.g. 16 weeks and 6 days which is expressed as 16 6/7 weeks
 -(KNOW THE MONTHS OF THE YEAR THAT HAS 30 or 31 days)
 -Subtract the LMP from the # of days of the month then add the rest of the days till the present
date of check up)

TO COMPUTE FOR EDD

 Naegele’s rule:
 If LMP starts in April-December. Subtract three months from the month of LMP, add seven days
to the first day of last LMP and add one to the year.
Example, LMP was April 24, 2020 (4-24-20) :
Subtract three months from (April).
Add seven days to (24).
Add one to the year, ( 2020, in this case)
THUS: 4 /24/ 2020- LMP
-3 +7 +1= 1/ 31/2021
EDD is January 31, 2021

 TO COMPUTE EDD FROM JANUARY TO MARCH LMP

Add 9 to the month of LMP
Also add 7 to the first day of last LMP
No need to add one to the year
For example, LMP was February 24, 2020
2/ 24/ 2020
+9/ +7/
------------
=12/ 01 (December 1 of the same year)

Weight Gain Recommendations For Pregnant Women

 With One Baby
Normal Weight-25-35 pounds
 With Twins
Normal Weight-37-54 pound
Qualitative amniotic fluid volume(AFV)
Normal 8-10 cm
Equivocal 6 cm
Abnormal <4 cm
Fundal Height – measures the size of the uterus in order to assess fetal growth and development during
pregnancy

TD VACCINE FOR MOTHERS

GRAVIDA _ PARA _
• Gravida - # of pregnancies
• Para - # of successful births/ deliveries
Five- Digit System
 • T-full term 38 – 40 weeks
• P-preterm deliveries (< 38 weeks)
• A-abortion
• L-living ChildrenLast Menstrual Period (LMP) - “Kailanpoangunangarawnginyonghulingregla-
LeopoldsManeuver- four specific steps in palpating the uterus through the abdomen in order to
determine the lie and presentation of the fetus.

History taking in its simplest form involves asking appropriate questions of patients or their relatives or
to obtain information to aid diagnosis.
Taking a history from a patient is a skill necessary for examinations and afterwards as a
professional
Specific questions vary depending on what type of history we take
The history should record key statements in the patient’s words

HISTORY TAKING
 Give the client an expectation, of what will occur during the interview and why assessment is
important to both client and the interviewer.
 Example on how to communicate the purpose of the assessment interview:
 "Today I'd like to focus on some concerns that are bothering you most. In order to find out
exactly what you’re concerned about, I’ll be asking you for some specific kinds of information.
This information will help both of us identify what you’d like to work on. How does this sound
[or appear] to you?"
 Make opening greeting to establish rapport.
 Listen and observe for use of facial expression, body language and verbal fluency to help
understand what is really troubling someone
 USE other means of communicating, especially where someone has a poor command of the
language or has hearing impairment.

THE ART OF HISTORY TAKING

 Diagnosis is revealed in the patient's history
 The basis of a true history is good communication between interviewer and patient.
 A good history is one which reveals the patient's ideas, concerns and expectations as well as any
accompanying diagnosis.
 The agenda, incorporating lists of detailed questions, should not dominate the history taking.
 Listening is at the heart of good history taking.
SETTING- The layout of the interview room can assist good interview.

PROCEDURE STEPS
STEP 01-Self introduction
Introduce yourself, identify your patient and gain consent to speak with them. Should you wish
to take notes as you proceed, ask the patients permission to do so.
STEP 02 - Presenting Complaint (PC)
This is what the patient tells you is wrong, for example: chest pain.
STEP 03 - History of Presenting Complaint (HPC)
Gain as much information you can about the specific complaint.
 Sticking with chest pain as an example you should ask:
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, 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?
STEP 04 - Past Medical History (PMH)
Gather information about a patients other medical problems (if any).
STEP 05 - Drug History (DH)
Find out what medications the patient is taking, including dosage and how often they are taking
them, for example: once-a-day, twice-a-day, etc.
STEP 06 - Family History (FH)
Gather some information about the patients family history, e.g diabetes or cardiac history. Find
out if there are any genetic conditions within the family, for example: polycystic kidney disease,
arthritis, obesity, cancer
STEP 07 - Social History (SH)
Ask about smoking and alcohol and if they use any illegal substances, for example: cannabis,
cocaine, etc.
STEP 08 - Review of Systems (ROS)
Gather a short amount of information regarding the other systems in the body that are not
covered in your HPC
STEP 09 - Summary of History-Complete the history by reviewing what the patient has told you.
Repeat back the important points so that the patient can correct you if there are any
misunderstandings or errors.
STEP 10 - Patient Questions / Feedback
During or after taking their history, the patient may have questions that they want to ask you. It
is very important that you don’t give them any false information.
STEP 11
End the interview by thanking them for their time

WHAT QUESTIONS
 OPEN QUESTIONS
o Open questions can be used to obtain specific information about a particular symptom
o For example: 'Tell me about your cough.' Or: 'How are you feeling today?”
"What problems brought you to the hospital (or clinic) today?”
o These open-ended, nondirective questions encourage the patient to report any and all
problems
o Compels the patient to provide more in-depth and insightful responses
o Facilitation techniques are employed to encourage and guide the patient's spontaneous
report
 CLOSED-ENDED QUESTIONS
 o Questions that generally limit the patient’s response to either a yes or a no or nod of the
head
o Are you feeling well today?
o Do you take your medications as directed by your physician?
 CONCLUSION
o Try to let patients tell you their story freely.
o When using questions, try to keep them as open as possible.
o Use all senses to 'listen'.
o Check that what we think is wrong is what our patient thinks is wrong.

Reference Materials:
Berman, Audrey.Kozier, Barbara. (Eds.) (2010) Kozier&Erb's fundamentals of nursing :concepts,
process, and practice  Upper Saddle River, N.J. : Pearson Prentice Hall
RLE Manual Book for Level 2
Muhrer, J. (2014). The importance of the history and physical in diagnosis.The Nurse
Practitioner,39(4), 35-36. doi:10.1097/01.npr.0000445726.93236.5e
Fawcett, T., &Rhynas, S. (2012). Taking a patient history: The role of the nurse.  Nursing
Standard (through 2013),  26(24), 41-6; quiz 48. Retrieved from
https://login.proxy038.nclive.org/login?
url=https://search.proquest.com/docview/922566059?accountid=10098