What makes a good history?

Taking a good history is the key to good clinical practice and 80% of diagnosis can be made on the history (Hampton et al. 1975), so recording/documenting it is essential.

Records may help judge the validity of a complaint or grievance, giving the practitioner’s explanation. They do not prove the truth of what was written, but do provide real support for what is said to have happened. If records are absent or inadequate, it reflects a lack of accountability and professionalism. Beware of the attitude ‘I’m just covering my back’!

‘At the root of most of the complaints put to me lie failures in communication. One way of ensuring that communications are improved and that patient care is not flawed is to make good records. At its lowest level, keeping records is a matter of cool self interest…’
William Reid, Health Service Commissioner (Reid 1995)

Common problems with record-keeping and documenting

  • Incomplete/inaccurate records
  • Inadequate or no record of observations
  • Failure to record administration of medicines/treatment
  • Omissions of date, time, name of patient, signature
  • Recording care as delivered when it wasn’t
  • Abbreviations (e.g. SOB can mean ‘short of breath’ to one person, and ‘son of a bitch’ to another!)
  • Ambiguous statements
  • Uncomplimentary statements about patients
  • No record of psychological/emotional care
  • No/inadequate assessment/evaluation
  • No record of care being delivered

Benefits of effective record-keeping

  • Continuity of care
  • Better communication and dissemination of information among the inter-professional team
  • Early detection of problems
  • An accurate account of planning, delivery of care and treatment
  • A high standard of care

Document the initial meeting

  • At least note down what you observed!
  • State how they approached you
  • Describe their general appearance
  • Do they look in pain?
  • Are they maintaining eye contact?
  • Are they smiling or do they look upset?

Don’t forget to read existing notes/referral letter/results.

Document the findings (using the Medical Model)

  • Presenting complaint (PC) – what the patient considers the reason for the consultation
  • History of presenting complaint (HPC) – how the condition manifested, when, why and where. Mechanism of injury
  • Past medical history (PMH) – to include past surgery and drug history (DH) medications/allergies/immunisations
  • Family history (FH) and social history (SH)
  • On examination (OE) clinical findings – record your findings from:
    • inspection
    • palpation
    • percussion
    • auscultation

Impression – what do you think is wrong with this patient?
Plan – include any further investigations
Management – treatment, referral and discharge plan
Discharge advice – health promotion/education

Developing the documentation further, you should review the relevant systems: skin, hands, mouth, eyes, cardiovascular system, respiratory system, abdomen, head and neck, nervous system, genitourinary system, musculoskeletal system.

Recording the information

  • Note the time of the examination
  • Dominant hand?
  • Record the anatomical position – draw it if you can (electronic records may have body map)
  • Record negative findings
  • Record the working diagnosis
  • Record treatment prescribed
  • Record the advice given, disposal time and sign the document

Remember this

‘If it is not recorded, it did not happen, you have not done it!’
Peter Fulkes QC (1997 cited in Roberts 2011)


Your task

Download and review the example history document from the Downloads section.

What do you think is good about this history? How do you think it could be improved?

Discuss your own strengths and weaknesses in record-keeping, and what factors influence this.

If you wish to find out more about UK nursing record keeping standards, we encourage you to read the NMC’s The Code which you will find in the Additional Reading section below.

Additional Reading

The Code, Professional standards of practice and behaviour for nurses and midwifes, NMC 2015.


References

Hampton, J. R., Harrison, M. J., Mitchell, J. R., Prichard, J. S., and Seymour, C. (1975) ‘Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients’. British Medical Journal [online] 2 (5969), 486–489. available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1673456/ [16 August 2018]

Roberts, S. (2011) ‘Learning Points from a Recent Case Involving Traumatic Injury’. Clinical Times: Focus on Assessment and Documentation August, 12–16: 14

Reid, W. K. (1995) Crookshank Lecture: Medical Attitudes and Patients’ Perceptions [online] available from http://www.theioi.org/downloads/1a5b5/ [4 July 2018]

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This article is from the free online course:

An Introduction to Physical Health Assessment

Coventry University