This is the process of gathering information about a patient’s physical, mental and social state. These pieces of information could be obtained from the patient, relative(s) or significant others.
Aims
· Gain a better understanding of patient’s problem
· Obtain useful information in formulating a nursing diagnosis
· Provide effective nursing care to the patient
· Give treatment
Requirements
· Table
· Chair
· Pen and paper
· Patient’s folder (Electronic/Manual)
· Vital signs tray
· Weighing scale/ Stadiometer
· Serene environment
Steps
1. Welcome patient and relative(s) and offer them seat(s)
2. Sit near them with electronic device/writing material
3. Establish rapport (refer procedure) and explain procedure
4. Initiate communication with patient and relative(s) with assurance of confidentiality
5. Establish eye contact with patient during history taking
6. Observe patient’s behaviour and reactions
7. Obtain information highlighting on the following:
· Demographic/Personal history – name, age, sex, address, occupation etc.
· Present psychiatric history – presenting complaints, onset, duration, etc.
· Past psychiatric history – previous episodes, treatments, duration, etc.
· Family history – family genogram (medical, surgical, psychiatric conditions, etc.)
· Developmental history – pre-natal, developmental milestone, malnutrition etc.
· Pre-morbid personality – mood, hobbies, habits etc.
8. Assess patient’s current mental state
9. Check and record the vital signs of the patient
10. Measure the weight and height of patient and record
11. Summarize the salient points and allow patient/relative(s) to ask questions the session
12. Express appreciation to patient and relative(s) and inform them on what to do next
13. Document findings in the nurses’ note/patient’s folder
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