Checklists for Clinical Nursing Skills

Chapter 2 Health assessment

Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-1 Taking a patient history

Comments

Goal: An accurate and concise patient history is obtained.

Excellent

Satisfactory

Needs practice

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 1. Identify the patient and place an ID band on the patient.  2. Review any documentation that has accompanied the patient (e.g. doctor’s letter, preadmission clinic information).  3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent.  4. Gather the necessary equipment. Equipment: admission forms.  5. Undertake a risk assessment, if indicated.  6. Perform hand hygiene.  7. Put on personal protective equipment (PPE), if indicated.  8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal.  9. Assess the situation for any potential danger to you or the patient. 10. Approach the patient, observing the patient’s response, airway, breathing and circulation, and conscious state. (Primary survey) 11. Invite significant others to be present for the history taking, if appropriate. 12. Commence the patient interview using appropriate styles of questioning and non-verbal communication and focusing techniques. 13. Collect bibliographical data. 14. Collect data regarding the patient’s physical symptoms. 15. Collect data regarding the patient’s past health history. 16. Collect data regarding the patient’s family history. 17. Collect data regarding the patient’s health and lifestyle practices. 18. Ensure all data are documented. 19. Clarify the important information collected and paraphrase to confirm understanding.

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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.