Tanta University

Faculty of nursing
Master Degree
2024 – 2025

HEALTH HISTORY AND INTERVIEW

UNDER SUPERVISION
ASSISTANT PROF
DR.REDA ABDELSALAM
Prepared by :-
1.Ahmed Mohamed Abdelmwgood
2.Amira Magdy Mohamed
Objectives :-

At the end of this seminar,the learner will be able to :-

1.Define health history
2. Recognize the importance of properly obtaining and recording a patient
history.
3.Describe content and format used to obtain health history
4.Define interview
5.Apply interviewing skills
Outlines
1. 1.Introduction
2. 1.Definition of health history
3. 2.Importance of proper health history
4. 3.content and format of health history
5. 4.Definition of interview
6. 5.interviewing skills
Introduction :-

Obtaining an accurate history is the critical first step in determining the

etiology of patient's illness. A large percentage of the time (70%), you will
actually be able make a diagnosis based on the history alone. The history
guides the rest of the assessment process: physical examination, x-ray and
laboratory studies, and special diagnostic procedures. When skillfully
obtained, the history often contributes in a significant way to an accurate
diagnosis.

Definition of Health History :-

The history is the foundation of comprehensive assessment. It is a written

picture of the patient’s perception of his or her past and present health status
and how health problems have affected both personal and family lifestyle.

Importance of proper taking health history :-

1. Provides an organized, unbiased, detailed, and chronologic description of

the development of symptoms that caused the patient to seek health care.
2.Provides the foundation for interprofessional communication to enable
many medical disciplines to collaboratively develop or alter a plan of care.
3.In addition, identifying the patient’s symptoms and changes in those
symptoms permits the patient care team to assess the effect of therapeutic
interventions and overall progress.

Basic Components of health history

1. Identification data of client
2. Chief complain
3. History of present illness
4. Past health history that include:-
5. Past medical history
6. Past Surgical history
7. Personally history and social history
8. Family history
9. Obstetrical history
10.Drug history
1.Identification data of client or Demographic information :-
( Name, Age / Sex, Occupation , Religion , Marital status , Date of examination
Monthly Income, Diagnosis , Date of surgery , Name of surgery )
2.Chief Complaint :-
 It is the main reason, which pushes the patient to seek medical advice
 It is usually a single symptom or occasionally more than one complaints
e.g.: chest pain, palpitation, shortness of breath, ankle swelling etc ....
 Chief complaints have to write or record on patent’s own words.
 It has to write as specific and clear.
 It should communicate present major problem or issue
 We should also mention the time, duration and frequency of the chief
complaint
 We can ask following questions to patients to get chief complaints :-
1. What brings your here?
2. How can I help you?
3. What seems to be the problem?

3.History of present illness

 It is the elaborative form of chief complaint
 Here we need to write the patients present illness in detail
 For each problem, we should identify associated symptoms,
precipitating factors and alleviating factors
 Avoid medical terminology and make use of a descriptive language that
is familiar too
 We should record details of present problem with- time of onset and
mode of evolution
 We should also add investigations related to present illness (if
available); treatment taken & its outcome (if available)
 Describe each symptom in chronological order or sequential order
 Always relay story in days before admission or begin with the time the
patient was last well E.g. one week before the admission, the patient fell
while gardening and cut his foot with a stone.
 Narrate in details
 In details of symptomatic presentation “OPQRST” The following key
words have to consider while describing symptoms
 E.g. In case of PAIN (Onset of the pain , Position/site ,Quality, nature,
character – burning sharp, stabbing, crushing, also explain depth of
pain – superficial or deep. Severity – How it affects daily work/physical
activities of patient? )
 Relationship to anything or other bodily function/position.
  Radiation: where moved to?
 Relieving or aggravating factors – any activities or position
 Timing – mode of onset (abrupt or gradual), progression (continuous or
intermittent – if intermittent ask frequency and nature.)
 Treatment received or/and outcome.

4.Past history of illness

 We should collect details on past illness like DM, HTN, CVA, MI, CAD,
IHD; CRF etc.
 Details should include signs and symptoms, course and treatment. E.g. if
diabetic- Mention time of Diagnosis/current medication
 We can also add general health of the patient including sleep pattern,
appetite, and stability of weight.
 Details of infectious disease history like Diphtheria, polio, tetanus,
mumps and measles etc.
 We can also add psychiatric illness history
 Allergic history – food , drug etc

5.Past surgical history

 Time/place/ and what type of operation.
 Note any blood transfusion and blood grouping.
 Date of surgery, Diagnosis, and perioperative course details

6.Personal history and Social history

 includes patient’s habits, and hobbies
 Smoking history - Amount, duration and type (Active or Passive)
 Drinking history - amount, duration
 Occupation, social and education background
 ADL, family social support and financial situation Family medical
history is important in identifying your patient’s risk for certain disease
states.
 Chronic illness or disease can include cancer, diabetes, autoimmune
disorders cholesterol, heart disease, hypertension, renal disease, and
mental Family history

7.Family History
 family tree
 It is the diagrammatic representations of patient’s family. Following
symbols are used to draw a family tree
8.Other Relevant History
 Drug History (DH)
 Always use generic name or put trade name in brackets with dosage,
timing and how long. Do not forget to mention
OCP/Vitamins/Traditional medicine
 Details of drug allergy
 Gyane/Obstetric history if female

 Small child, obtain the history from the care giver. Make sure that you
are talking to right care giver.
 Travel and sexual history if suspected STI or infectious disease.

Definition of Interview :-
Medical interviewing, which includes both clinician- and patient-centered
approaches, serves as the backbone for most clinical encounters.
Interviewing is also one of the most difficult clinical skills to master. The
demands made are both intellectual and emotional. The analytical skills of
diagnostic reasoning must be balanced with the interpersonal skills needed to
establish rapport with the patient and facilitate communication.

Interviewing skills
Facilitating a patient-centered approach Include:-
1. Open-ended questioning
2. Non-verbal communication skills such as purposeful silence or non-
verbal encouragement,Attentive listening, and summarizing or
paraphrasing.
3. Effective patient–physician communication and shared decision-making
require the incorporation of these techniques into everyday practice.
Reference

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Fawcett, T. & Rhynas, S. (2012). Taking a patient history: The role of the nurse.
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Kaufman, G. (2008). Patient assessment: Effective consultation and history taking.

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