Interview Skills & History

History taking and
Interviewing
By:
Najma Waqas
SFINHS
"The most important practical
lesson that can be given to
nurses is to teach them what to
observe- how to observe”
~Florence Nightingale, 1859
OBJECTIVES
At the end of this session the students will be

able to:
✓ Explain the purpose, process & principles of
interviewing.
✓ Discuss the process of investigating positive
findings during the health history.
✓ Utilize effective interviewing techniques to collect
health history information.
✓ Identify the major categories of a complete health
history.
✓ Obtain and record a client health history.
Interviewing??
Interviewing is a goal directed purposeful
interaction between 2 people
Health History??
Health history is the collection of subjective data

provided by the client and compiled by the nurse.
It provides information about client’s present and
past health status, practices, perceptions,
knowledge, and attitudes about their health
Purpose
Gather information to base nursing care.
Establish a helping relationship (promoting, motivating,
supporting)
Identifying health status, concerns, & problems.
Screening purpose.
Identifying need for education
TO GAIN INFO & GIVE INFO & TO ESTABLISH A

TRUSTING SUPPORTIVE RELATIONSHIP
Interview approaches
Directive: Formal , structured , Usually
content focused, control & closed ended.
In-Directive: Informal, & Unstructured,

process, freedom, open ended.
Setting the stage for the interview
• Reviewing the charts: age, gender, the problem
list, medication list, allergies
• Your Mindset: open and respectful of human
regardless of differences in social class,
ethnicity, age etc
• Your Behaviour: postures, gesture, eye contact,
words, calm, smile and unhurried
Setting the stage Cont…
• Your Appearance: cleanliness, neatness,
conservative dress, ID cards
• Note Taking: points or details
• Silence:
• Touch: Procedural/ non procedural, culturally
determined
Environment:
» Privacy: separate, no visitors, curtain
» Noise: Decrease interruptions,
disturbances
» Seating: Face to Face, chair, eye contact
» Lighting: Adequate, facial expressions
» Temperature: not hot, not cold
» Comfort & Safety
Phases of Interviewing Process
Preparatory
Ensure that the environment is conducive.
Arrange seating 3 – 4 feet apart.
Interviewer seating at 45° angle to patient.
Collect background information from previous
charts.
Introductory
Interviewer introducing self to patient
Explain purpose of interview
Ensure confidentiality of information
Provide for patient needs before starting
Phases of Interviewing Process
Working
Nurse gathers info for subjective data
Excellent communication skills are needed
Active listening
Eye contact
Open-ended questions
Termination
Inform patient when nearing end of interview
Ensure patient knows what will happen with
information shared
Offer patient chance to add anything
Types of Nursing Health History
Complete Health History
It is taken on initial visits to health care
facilities.
Interval Health History
Collecting information in visits following
the initial data base is collected.
Problem- Focused Health History
Collecting data about a specific problem.
14
Complete Health History/
Components of Adult health History
Biographical Review of systems

Reason for seeking Psychological history
health care Functional Assessment
Present health/Illness Perception of health
Past health
Family health
Biographical Data
Full name
Address and telephone numbers (permanent contact
of client)
Birth date and birth place.
Gender and marital status.
Religion and race.
Occupation (usual and present)
Source of referral.
Usual source of healthcare.
Source and reliability of information.
Date of interview.
16
Reason for Seeking Healthcare
Begin with reason for seeking care (chief
complaint is previously used term).
Document the onset, duration, precipitating
factors.
Document frequency, duration of complaint.
Associated symptoms i.e. Nausea/Vomiting.
Alleviating/aggravating factors.
Reason for Seeking Healthcare
ROS (Review of system)
Relevant family, occupational History
Elicit a complete description from patient
Document using the patient’s own words.
Past Health History
Past general health
Childhood illnesses
Accidents / injuries
Hospitalizations/surgeries
Acute and chronic illnesses
Immunization status
Allergies, medications, transfusions
Obstetric History
Family History
Important to know in order to determine risks
Status of family members, parents, siblings, grandparents,
spouse/significant other and children
Family history of communicable diseases.
Heredity factors associated with causes of some diseases.
Strong family history of certain problems.
Cause of death of the family members "immediate and
extended family".
Current Health
The purpose is to record major, current, health
related information.
Allergies: environmental, ingestion (food), drug,
other.
Habits: "alcohol, tobacco, drug, caffeine“
Medicines (including OTC (over the counter) /Herbal/Vitamins
taken
regularly, by doctor or self prescription.
Exercise pattern
Sleep pattern (daily routine)
Review of Systems: ROS
Review past and present health status

of each body system.
Review health maintenance.
A Head-to-Toe approach
May elicit new information
Psychosocial History
This includes:
How client and his family cope with
disease or stress & how they respond
to illness and health.
Assess if there is psychological or social
problem & if it affects general health of
the client.
Family relationships 23
Psychological Function
Cognitive – memory, comprehension
Response to illness and health
Psychiatric history, meds, anxiety?
Cultural considerations
Coping difficulties
Domestic/child abuse
Functional Assessment
Activities of Daily Living (ADL)

Sleep and Rest
Nutrition/problems with diet, weight
Alcohol/Substance abuse
Smoking history
Perception of Health
How the patient defines health
Patient’s views on his health status
What are patient’s expectations
pertaining to health and health care
Assessment of Interpersonal
Factors
This includes:
Ethnic and cultural background, spoken
language, values and health habits
Self concept, perception of strength, and
desired changes
Sexuality developmental level & concerns
Stress response, coping pattern, support
system, perceptions of current anticipated
stressors.
27
References
1. Nasir SA & Inayatullah M. Bedside Techniques:
Methods of clinical examination. 2006; 3rd edition:
Saira publishing; Multan. Pp. 106-136.
2. Lynn S. Bickley MD. Bates' Guide to Physical
examination and History Taking. 2008; 10th edition:
Lippincott Williams & Wilkins.
3. Clinical Methods, 3rd edition: The History, Physical &
Laboratory Examinations [online data base] retrieved
from; http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?
book=cm
7/9/2020 28

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Interview Skills & History

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History taking and

At the end of this session the students will be

Health history is the collection of subjective data

TO GAIN INFO & GIVE INFO & TO ESTABLISH A

In-Directive: Informal, & Unstructured,

Biographical Review of systems

Review past and present health status

Activities of Daily Living (ADL)

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