Strategies for Obtaining an Accurate Patient History

by David Warren, FNP, ACNP, ENP

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    00:01 Hello everyone and welcome to this video on obtaining an accurate and an efficient patient history.

    00:07 My name is David Warren and I'm certified as a family nurse practitioner, acute care nurse practitioner, and emergency nurse practitioner.

    00:14 I really want to share with you my top tips on obtaining histories from patients and how that impacts our clinical decision making process.

    00:22 Number one, the foundation of quality care always starts with a patient history.

    00:28 An accurate and a complete history can never be underestimated, especially in the healthcare setting.

    00:33 It helps us make those informed clinical decisions, and it really helps us tailor the treatment plan specifically to that patient, and not just generalized based on a diagnosis or a disease process.

    00:47 Number two, the second point I want to make to you is effective communication.

    00:52 The importance and the significance of effective communication skills in obtaining a patient history cannot be underestimated.

    00:59 Whenever you go see a patient, you have to develop trust with that patient.

    01:04 In the emergency department setting, which is where I work, it is extremely challenging to go see a patient that you've never seen before or may have never seen before, and to develop that trust with them in a matter of seconds.

    01:15 And you have to be really good at that or the patient will not be honest with you in their patient history.

    01:21 You need to do things like active listening.

    01:23 Are you listening to what the patient says? Are you allowing the patient to tell their story? Or are you interrupting every two seconds to ask a question? And we're all guilty of that.

    01:32 But whenever you ask the patient, what is going on today, start with an open-ended question.

    01:37 What brings you to the emergency department today? Or what brings you into the clinic today? And let the patient answer that question in the way that they see fit.

    01:44 Some will answer it in a shorter time and others will answer it in a longer time frame, but you need to stick to those active listening techniques and open-ended questions.

    01:54 You really also need to create a comfortable and non-judgmental environment, and you need to encourage the patient to share critical information, and that can sometimes be challenging for patients, especially whenever they come in with things that they don't really want to talk about.

    02:09 but reiterating that making the best decision for them and helping them on their journey, they need to share the critical information that you need to make those decisions.

    02:19 Number three, I want to highlight the importance of digital tools and electronic health records.

    02:24 Before I go see a patient or before I ever lay eyes on the patient, I will look in the electronic health record to see if they have prior visits.

    02:32 Have they been to the emergency department before? And if so, why did they come and what was the outcome? Do they have chronic medical problems? Are they followed by multiple specialty providers? Or have they never had care before? Have they never been to the emergency department before? Is this their first visit to this healthcare facility? All of that plays a role in how I will address the history to the patient or how I will obtain a history from the patient.

    02:59 If they have multiple specialty visits, I will always bring that up.

    03:02 When did you follow up with your specialist last? What did they say? How are they managing your condition? Versus if they don't have any chronic medical problems, that will certainly change how I approach the history.

    03:13 And then I will look at the nursing notes from today and the vital signs from today.

    03:18 Why did they tell the nurse that they are seeking care, or what are their current vital signs? I look at all of that before I ever enter the room to even talk to the patient.

    03:28 I want to emphasize cultural sensitivity and patient trust.

    03:32 The importance of cultural competence in obtaining an accurate patient history can't be underestimated.

    03:37 The patient may not look the same way that you look.

    03:40 They may not talk the same way that you talk.

    03:42 They may not have the same background or the same educational history that you have.

    03:47 And you have to be able to navigate that.

    03:49 You have to be able to address the patient the way that they want to be addressed.

    03:52 And you have to talk to the patient the way that they may want to be talked to.

    03:56 And you have to earn the patient's trust.

    03:58 Having those open discussions about a patient's health really starts with being culturally sensitive and developing their trust.

    04:05 Developing their trust may take some time.

    04:07 You may only have a few seconds or a few minutes, but you need to work at asking those open-ended questions, presenting a non-judgmental attitude, having those non-verbal cues that will allow the patient to know that they are safe opening up to you and talking to you and providing you with the necessary information so that you can make medical decisions and a treatment plan on their behalf.

    04:28 I want to share with you the red flags and the critical information that you need to pick up on during patient histories.

    04:34 A lot of the times when you're talking to a patient, they may give you inconsistent things, or they may tell you something that is blatantly false, or something that you read in the prior medical record that doesn't match up with today.

    04:45 And you really need to be able to pick up on those things and address them.

    04:49 It really goes back to our prior point about looking in the electronic medical record at prior visits.

    04:55 knowing what their prior history is and knowing when the patient can be inconsistent and being able to deal with that and address it.

    05:02 It's important to recognize that and to call the patient out in the moment and not wait until minutes or hours after to go back and address it.

    05:10 And of course that's not being judgmental it's stopping the patient and saying hey I realized maybe you said X Y & Z did you really mean that or I read this in your medical record can you tell me a little more about that using those active listening techniques and those open-ended questions to address those red flags and that critical information because if you are making patient decisions or if you're making diagnostic decisions upon false information that certainly will come back on you.

    05:37 You need to be able to pick out those red flags, those blatant lies that patients may tell, and you need to address that in real time with the patient.

    05:46 Thank you so much for watching this video on efficient and accurate patient history.

    05:51 I hope you found the video helpful.

    About the Lecture

    The lecture Strategies for Obtaining an Accurate Patient History by David Warren, FNP, ACNP, ENP is from the course Role Transitions (APRN).

    Included Quiz Questions

    1. Obtaining a patient history
    2. Performing a physical examination
    3. Creating a differential diagnosis
    4. Providing counseling on the plan of care
    5. Updating the electronic health record
    1. Questions should be open-ended.
    2. Only ask leading questions.
    3. Ask double-barrel questions.
    4. Basic information can be assumed while taking a history.
    1. Previous patient visits
    2. Nursing notes from today's visit
    3. The patient's co-morbidities
    4. List of the patient's preferred diet
    5. The patient's level of trust in healthcare providers.

    Author of lecture Strategies for Obtaining an Accurate Patient History

     David Warren, FNP, ACNP, ENP

    David Warren, FNP, ACNP, ENP

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