ARSI UNIVERSITY

College of Health Sciences

Department of Nursing

Interviewing and the Health History

By- Abenet M (Lecturer)

November , 2015
Asella, Ethiopia
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 OUTLINE OF PRESENTATION
 The health history and interviewing
The health history
 Purpose of history taking
 Phases of history taking
Interviewing
 The approaches to the interview
 The sequence of the interview
 The techniques of skilled interviewing
Formats for collecting assessment data
The comprehensive health history
Summary
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 Session Learning Objectives

• Describe the purpose of history taking

• Identify the phases of history taking

• Apply the techniques of skilled interviewing when

taking a health history
• Evaluate the different approaches of health
assessment /formats for collecting assessment data
• Conduct a comprehensive health history of all the
components of a client
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 Purpose of History taking

Establish a trusting relationship between the

nurses and the patients
Develops understanding about the patient
Helps the patient to feel understood
Guides on which body parts or systems to focus
Establish a therapeutic relationship
Gather pertinent information
Formulate a treatment plan

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 Phases of History taking
Introductory phase: the nurse introduces self
and explains the purpose of history taking or
interview.

Working phase: this is the actual data collection

phase.

Closure phase: summarizes information

obtained from the patient during the working
phase

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 Guidelines for effective History taking
 Great the patient, call by name and give
attention
 Make sure that the patient’s comfort and privacy
is kept:
 Never be in a hurry even when you are in limited
time
 Design questions appropriately
 Facilitation
 Reflection
 Clarification
 Empathetic response
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 The Health History & interview
• The health history interview is a conversation
with a purpose.
• Unlike social conversation, in which you express
your own needs and interests with responsibility
only for yourself, the primary goal of the
clinician–patient interview is to improve the
well-being of the patient.
• Communicating and relating therapeutically
with patients are the most valued skills of clinical
care.

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 The Health History & interview

• Establishing a supportive interaction enhances

information-gathering and itself becomes part
of the therapeutic process of patient care.

• The scope and degree of detail depend on the

patient’s needs and concerns, the clinician’s
goals for the encounter, and the clinical setting
(e.g., inpatient or outpatient, amount of time
available, primary care or subspecialty).

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 The Health History & interview

• For new patients, regardless of the setting, you

will do a comprehensive health history.

• For other patients who seek care for a specific

complaint, such as a cough or painful
urination, a more limited interview tailored to
that specific problem may be indicated,
sometimes known as a problem-oriented
history.

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 The Approach to the Interview

• Taking Time for Self-Reflection

• Reviewing the Chart
• Setting Goals for the Interview
• Reviewing Clinician Behavior and Appearance
• Improving the Environment
• Taking Notes

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 The sequence of the interview
 Greeting the patient and establishing rapport
(relationship)
 Inviting the patient’s story
 Establishing the agenda for the interview
 Expanding and clarifying the patient’s story
 Creating a shared understanding of the
problem(s)
 Negotiating a plan (includes further evaluation,
treatment, and patient education)
 Planning for follow-up & closing the interview.

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 The techniques of skilled interviewing

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 Group Work Presentation!!
 Identify the techniques of skilled interviewing
 Describe the technique
 Present with one example

 Select a chair person and a reporter

 You have given 5 minutes for discussion 3
minutes for presentation for each group

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 The techniques of skilled interviewing
Includes
Active listening,
Adaptive questioning,
Non – verbal communication,
Facilitation,
Echoing,
Empathic response,
Validation,
Reassurance,
Summarization and highlighting transitions
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 The techniques of skilled …

1. Active listening
Underlying all specific techniques of interviewing
is the practice of active listening.

Active listening is the process of fully attending

to what the patient is communicating, being
aware of the patient’s emotional state, and
using verbal and nonverbal skills to encourage
the speaker to continue and expand.

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 The techniques of skilled …

2. Adaptive Questioning:
 Learn to adapt your questioning to the patient’s
verbal and nonverbal cues.
 There are several ways you can ask questions
that add detail to the patient’s story

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 The techniques of skilled …

2. Adaptive Questioning:
 Directed questioning—from general to specific.

 It is useful for drawing the patient’s attention to

specific areas of the history.
Eg “Tell me about your chest pain?”
 Directed questions should not be leading
question.
Eg. “Did your stools look like tar?”
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 The techniques of skilled …

2. Adaptive Questioning:
 Asking a series of questions, one at a time.
 Ask one question at a time.
 Offering multiple choices for answers.
For patients unable to describe their symptoms
without help.
Eg “Is your pain aching, sharp, pressing, burning,
shooting, or what?”
 Clarifying what the patient means.

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 The techniques of skilled …

3. Nonverbal Communication
 Pay close attention to eye contact, facial
expression, posture, head position and
movement such as shaking or nodding,
interpersonal distance, and placement of the
arms or legs
Matching your position to the patient’s can
be a sign of increasing rapport.
Moving closer or engaging in physical
contact can convey empathy

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 The techniques of skilled …

4. Facilitation
 Use facilitation when, by posture, actions, or
words,
 Encourage the patient to say more like “Mm-
hmm,” “Go on,” or “I’m listening”

 Pausing with a nod of the head or remaining

silent, yet attentive and relaxed, is a cue for the
patient to continue.

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 The techniques of skilled …

5. Echoing/Reflection
 Simple repetition of the patient’s words
encourages the patient to express both factual
details and feelings, as in the following example:
 Patient: The pain got worse and began to
spread. (Pause)
 Response: Spread? (Pause)…

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 The techniques of skilled …

6. Empathic Responses
 Conveying empathy is part of establishing and
strengthening rapport with patients.
 As patients talk with you, they may express—
with or without words—feelings they have not
consciously acknowledged.
 These feelings are crucial to understanding their
illnesses and to establishing a trusting
relationship.

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 The techniques of skilled …

6. Empathic Responses…
 To empathize with your patient you must first
identify his or her feelings.
 Responses may be as simple as “I understand”
 Offering a tissue to a crying patient
 Gently placing your hand on the patient’s arm
to show understanding.
 When you give an empathic response, be sure
that you are responding correctly to what the
patient is feeling

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 The techniques of skilled …

7. Reassurance
 When you are talking with patients who are
anxious or upset, it is tempting to reassure them.
 The first step to effective reassurance is
identifying and accepting the patient’s feelings
 The actual reassurance comes much later after
you have completed the interview, the physical
examination, and perhaps some laboratory
studies.

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 The techniques of skilled …

7. Reassurance…
 At that point, you can interpret for the patient
what you think is happening and deal openly
with the real
 Premature reassurance may block further
disclosures, especially if the patient feels that
exposing anxiety is a weakness.
 Avoid premature reassurances.
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 The techniques of skilled …
8. Summarization
 Giving a capsule summary of the patient’s story
 It indicates to the patient that you have been
listening carefully.
 It can also identify what you know and what you
don’t know.
 You can use summarization at different points in
the interview
 Allows the clinician to organize clinical reasoning
and to convey thinking to the patient

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 The techniques of skilled …

9. Highlighting Transitions
 Patients have many reasons to feel worried and
vulnerable.

 To put them more at ease, tell them when you

are changing directions during the interview.

 This gives patients a greater sense of control.

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 The techniques of skilled …

9. Highlighting Transitions…
 As you move from one part of the history to
another and on to the physical examination,
orient the patient with brief transitional phrases
like
“Now I’d like to ask some questions about your
past health.”
 Make clear what the patient should expect or do
next . . .
“Now I’d like to examine you. Please get
completely undressed and put on this gown.”
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 Formats for collecting Assessment data

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 Formats for collecting Assessment data

• There are three commonly used formats for

collecting assessment data,
1. Body systems approach,
2. Functional patterns approach, and
3. Human response pattern.

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 Body systems approach

 In this approach the nurse observes and records

data about each of the body systems
 The drawback of this approach is that the
information obtained tends to be incomplete
needed to perform a holistic nursing
assessment.
 It is difficult to develop nursing diagnosis.
 There is a strong trend toward the use of nursing
models.
 Nurses need to know about it to communicate
with other health care providers
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 Functional patterns approach

 It is developed by Marjory Gordon,

 Organizes data into 11 categories of information,
 Describe a sequence of behavior over time
rather than isolated events.
 Permits the nurse to identify functional patterns
and dysfunctional patterns

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 Human response pattern

• This approach is commented by experts.

• Many contemporary experts of nursing tend to

use the functional health pattern approach very
frequently.

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 COMPREHENSIVE HEALTH HISTORY

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 What are the Components of the
Comprehensive Health History for Adults?

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 Components of the comprehensive health history

 For adults elements of the comprehensive health

history includes
Identifying Data and Source of the History,
Chief Complaint(s),
Present Illness,
Past History,
Family History,
Personal and Social History, and
Review of Systems.

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 The techniques of skilled …

Date and Time of History

• The date is always important in rapidly
changing conditions.
• The time should also be added.
• You are strongly advised to routinely document
the time you evaluate the patient.

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 1. Identifying Data/General information

• Identifying data: Includes biographical data such

as age, gender, marital status, and occupation.
• Source of the history: usually the patient, but
can be family member, friend, police, letter of
referral, or the medical record.

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 1. Identifying Data…

 Documenting source of history has the following

purpose:
To assess the value and possible bias of the
information
To comment on the probable reliability of the
source of data
 If appropriate, establish source of referral, since
a written report may be needed

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 2. Chief Complaint(s)
 This is the starting point of the main part of the
history
 The one or more symptoms or concerns
causing the patient to seek care or advice.
 Make every attempt to quote the patient’s own
words.
 The duration of the complaint should be
specified.
Eg. “Fever of 3 days duration”
 Some times patients have no overt complaint;
they ascertain their purpose in – stead.
Eg. “I have come for check up”.
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 3. History of Present Illness/HPI
• This section of the history is a complete, clear,
and chronologic account of the problems
prompting the patient to seek care.
• Amplifies the Chief Complaint
• It usually identifies major disease mechanisms
and may even establish the diagnosis when
symptoms are precise.
• It is also important to include “pertinent
positives” and “pertinent negatives”.
• These designate the presence or absence of
symptoms relevant to the differential diagnosis

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 3. History of Present Illness…

• Includes patient’s thoughts and feelings about

the illness
• May include medications, allergies, habits of
smoking and alcohol,
• Effect of treatment: patients might have taken
drugs prior to their presentation to the health
institution.
• It is very important to ask about the effect of
such drugs on the illness.

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 3. History of Present Illness…

The principal symptoms should be well

characterized, with descriptions of
1. Location,
2. Quality or character
3. Quantity or severity,
4. Timing (onset, duration, and frequency),
5. The setting in which they occur,
6. Aggravating or relieving factors
7. Associated manifestations.

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 3. History of Present Illness…
Location,
• Pinpoint the body systems or organs involved.
• The character and location of the complaint should be
described well.
• If you take headache as example, What is the location? Is
it frontal or occipital, Is it unilateral or bilateral? Does it
radiate?
Quality,
• If we take pain as an example, it is important to ask
whether the pain is: Stabbing, Burning, Pricking-
Penetrating, Aching- Painful, Radiating
• Usually a person will equate a symptom with an analogy;
by stating it
Eg. “My chest pain feels like a knife is being thrust in
my chest”.
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 3. History of Present Illness…

Quantity or severity,

• The clinician need to quantify the symptoms

according to the level of intensity, how it affects
activities of daily living, frequency, volume,
number and size, or extent of the symptom

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 3. History of Present Illness…

Timing
• Ask whether the onset was abrupt or gradual,
intermittent or persistent, short lived or constant,
and steady or increasing in severity.
• Whether the symptom stays the same in
intensity or changes with time, the frequency,
and whether it wakes the patient from sleep
should be documented.

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 3. History of Present Illness…
The setting in which they occur,
 This is the description of where and what the
person was doing when the symptom occurred.
Aggravating or relieving factors
 Identify what worsens (aggravates) or relives
(alleviates) the symptom.
Eg. Does the chest pain change with exercise,
emotional upset, or rest?
 A chest pain can be worsened by strenuous
exercise or effort/exertion/.
 There can also be relieving factors for pains.
Ex. Rest usually promptly relieves upper gastro
intestinal pains, like duodenal ulcers.
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 3. History of Present Illness…

Associated manifestations.
 Some disorders produce symptoms in more than
one body parts.
Eg. A person with congestive heart failure may
have swollen ankles and abdomen and may
experience shortness of breath.

Note: Always remember, the data flows

spontaneously from the patient, but the task of
organization is yours.

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 3. History of Present Illness…

Example
Migraine headaches; A 54 years old women with
migraine headaches since childhood, with a
throbbing vascular pattern and frequent nausea
and vomiting.
 Headaches are associated with stress and relived
by sleep and cold compress.
 There is no papilledema, and there are no motor or
sensory deficit on the neurologic examination.

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 3. History of Present Illness…

Example
 The differential diagnosis includes tension
headache, also associated with stress, but there is
no relief with massage, and the pain is more
throbbing than aching.
 There are no fever, stiff neck, or focal finding to
suggest meningitis, and the life long recurrent
pattern makes subarachnoid hemorrhage unlikely
(Usually described as “the worst headache of my
life”)

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 4. Past History

This includes prior illnesses, injuries, childhood

illness, operations, hospitalization and medical
interventions from infancy onwards.

Childhood illnesses, such as measles, rubella,

mumps, whooping cough, chicken pox,
rheumatic fever, scarlet fever, and polio are
included in the Past History.

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 4. Past History

Medical (such as diabetes, hypertension,

hepatitis, asthma, HIV disease, information
about hospitalizations, number and gender of
partners, at-risk sexual practices);

Surgical (include dates, indications, and types

of operations);

Accident / Injuries head injuries, burns, auto

accident, fracture…

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 4. Past History

Obstetric/gynecologic (relate obstetric history,

menstrual history, birth control, and sexual
function);and

Psychiatric (include dates, diagnoses,

hospitalizations, and treatments).

Should also cover selected aspects of Health

Maintenance, including Immunizations.

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 4. Past History

History of blood transfusion

Each of these conditions should be described in

terms of the approximate date of occurrence,
the magnitude of the problem, place and
duration of admission, what was given or
done, and the outcome of the problem.

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 5. Family History

The family history of the patient is very important

because it provides valid information about the
health of the family.
Ask the person about family history of disorders
that may be influenced by heredity.
Also ask about family allergies, deformities, or
serious illnesses.
Outlines or diagrams of age and health, or age
and cause of death of siblings, parents, and
grandparents.

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 5. Family History

Review and document presence or absence of

the following specific illnesses in the family,
Hypertension, coronary artery disease, elevated
cholesterol levels, stroke, diabetes, thyroid or
renal disease, cancer (specify type), arthritis,
tuberculosis, asthma or lung disease, headache,
seizure disorder, mental illness, suicide, alcohol
or drug addiction, and allergies, as well as
symptoms reported by the patient.
Assess similar illness or symptom in the family

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 6. Personal and Social History

The Personal and Social History captures the

patient’s personality and interests, sources of
support, coping style, strengths, and fears.

It should include: occupation and the last year

of schooling; home situation and significant
others; sources of stress, both recent and long-
term;

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 6. Personal and Social History

Early development; eg place of birth

Education: school history, achievements and
failure
Marital status: whether the patient married or
not
Work record; type of work, age begun, income,
occupational hazards and attitudes to work.
Home surroundings, their sanitation condition,
the possible existence of over crowding or of
loneliness.
Habits: dietary history, history of substances like
alcohol, tobacco, khat, etc
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 7. Review of Systems

The Review of Systems questions may uncover

problems that the patient has overlooked,
particularly in areas unrelated to the present illness.
Document presence or absence of common
symptoms related to each major body system.
It gives a clear understanding of the present illness.
It is a double check on the history of present illness.
It guides the examiner to concentrate on specific
symptoms during the physical examination
One should know that there is no need to repeat
compliant already recorded in the history of
present illness
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 7. Review of Systems

Some clinicians do the review of systems during

the physical examination, asking about the ears,
for example, as they examine them.

If the patient has only a few symptoms, this

combination can be efficient.

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 7. Review of Systems

General. Usual weight, recent weight change,

any clothes that fit more tightly or loosely than
before. Weakness, fatigue, fever.

Skin. Rashes, lumps, sores, itching, dryness,

color change, changes in hair or nails.

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 7. Review of Systems
HEENT/Head, Eye, Ear, Nose, Mouth and Throat:
 Head: Headache, injuries, dizziness, lightheadedness
 Eyes: vision, glasses, blurring, photophobia, itching,
pain, redness, excessive tearing, spots, flashing lights,
glaucoma, cataracts, etc
 Ear: hearing problem, tinnitus, vertigo, earaches,
discharge, etc. If hearing is decreased, use of hearing
aids.
 Nose and sinuses: frequent colds, nasal stiffness,
nasal discharge, itching, nasal bleeding, etc
 Mouth and throat: conditions of teeth and gums, sore
tongue, frequent sore throat, and hoarseness of voice,
dry mouth, oral trash, dental caries, bleeding gums, etc
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 7. Review of Systems

Neck: pain, stiffness, swollen glands, lumps,

goiter, etc

Lympho-glandular system: enlarged glands,

lumps in the breasts, discharge from the nipples,
descent of testis

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 7. Review of Systems

Respiratory system: cough, production of

sputum, hemoptysis, difficulty of breathing,
wheezing, chest pain, bronchitis, emphysema,
pneumonia, and tuberculosis, shortness of
breath, etc

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 7. Review of Systems

Cardiovascular System: dyspnea (Degree of

exercise tolerance), orthopnea (number of
pillows required), cough, hemoptysis, chest pain,
hypertension, edema, etc

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 7. Review of Systems

Gastrointestinal System: difficulty of

swallowing, heartburn, nausea, vomiting,
appetite change, abdominal pain, constipation,
diarrhea, food intolerance, excessive bleaching
or passing of gas, frequency of bowel movement
including the color and amount and stool
passed, rectal bleeding, tarry stool,
hemorrhoids, and jaundice.
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 7. Review of Systems

Genito- Urinary System:

Urinary Tract
 Flank pain, polyuria, nocturia, pain on
micturation, retention, change in color of urine,
urgency, frequency, hesitancy, dribbling,
incontinence, or passage of stone during
urination.

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 7. Review of Systems

Genitals
Male: Hernias, discharge from the urethra or
sores on the penis, testicular pain or masses
Females: Vaginal discharge, and/or itching,
Menstrual History: menarche, frequency,
duration of bleeding, amount of bleeding, history
of post menopausal bleeding, history of bleeding
between periods, or after intercourse.
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 7. Review of Systems

Musculoskeletal system: muscle or join pains,

stiffness, arthritis, gout, and back ache. If
present describe location of affected joints, or
muscles, presence of any swelling, redness,
pain, weakness or limitation of motion or activity;
include timing of symptoms (Eg Morning or
evening), duration, and any history of trauma.

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 7. Review of Systems

Central Nervous System/Neurologic: history

of fainting, seizures, weakness, paralysis,
numbness, or loss of sensation, tingling
sensation, tremor or other involuntary
movements, poor memory, headache,
disturbance of speech, disturbance of sphincter
control, etc.

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 7. Review of Systems

Endocrine: Thyroid trouble, heat or cold

intolerance, excessive sweating, excessive thirst
or hunger, polyuria, change in glove or shoe
size.

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 7. Review of Systems

Psychiatric: nervousness, tension, delusion,

hallucination, mood, including depression,
memory change, and suicide attempts, if
relevant.

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 Any Question, Comment, Suggestion?

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 Reading Assignment?

 Read “Recording the history and physical

examination: The case of Mrs. N” on pages 16
– 20 of Bates B. A Guide to Physical
Examination and History Taking, 2007
 Critique the history against the components of
comprehensive health history you learn
 Submit the critique in a written paper for the next
week
 Prepare your self for the coming quiz

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 Role play Activity!
Objective: Apply the techniques of skilled
interviewing when taking a health history

• Form two group

• You have given 10 minutes
• One will take the role of the nurse/health care
provider
• Another one from the group will take the role of
the patient.

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 Summary
Health history is the most important part of health
assessment
To get complete, accurate, factual and relevant data,
one has to apply the techniques of skilled interviewing
The techniques of skilled interviewing includes; active
listening, adaptive questioning, non – verbal
communication, facilitation, echoing, empathic
response, validation, reassurance, summarization and
highlighting transitions
The elements of comprehensive history includes;
Identifying data and source of the history, chief
complaint(s), present illness, past history, family history,
personal and social history, and review of Systems.

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 Any Question, Comment, Suggestion?

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 I THANK YOU ALL!!!!!!

PEACE FOR ALL !!!!!!

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 Points that will be addressed in the recupp
1. ____Is the actual data collection phase
2. What is the difference between comprehensive and problem
oriented/focused history
3. What are the techniques of skilled interviewing? Mention
three of them
4. Which format for collecting assessment data is currently
promoted to be used by nurses?
5. Describe cc?
6. What is the importance of including pertinent positives and
negatives in HPI?
7. What are the points/factors that the clinician use to
characterize the principal symptoms in the HPI?
8. What points you are going to ask your client in past history
9. What points you are going to ask your client in family history
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 Case Study
 A 55 years old women presents with complain of
headaches. She has had increasing problems
with frontal headaches. These are usually
bifrontal, throbbing, and mild to moderately
sever. Headaches are associated with stress
and relived by sleep and cold compress. There
are no fever and stiff neck. When questioned
further, she has noticed nausea and vomiting
with the headache.
 Based on this description, which of the seven
attributes of this symptom have NOT been
addressed?
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