THE HEALTH HISTORY AND THE THERAPEUTIC INTERVIEW

Almost everything you will ever know about a patient arrives first as words. Before you lay a stethoscope on a chest or press a fingertip into an abdomen, the patient tells you where it hurts, when it started, what they took for it, and what they are afraid it means — and study after study finds that the history alone points to the correct diagnosis in the large majority of cases. The interview is therefore not the polite preamble to the “real” assessment; it is assessment, and it is a skill with technique, sequence, and error modes exactly like auscultation has. This chapter teaches you how to prepare the room and yourself, how to open with a question that produces information instead of a yes, how to analyze a symptom with OLDCARTS or PQRSTU, how to move through a review of systems without turning it into an interrogation, how to adapt for a toddler, a teenager, an interpreter, or an eighty-eight-year-old with hearing aids in the drawer — and how to recognize the sentence in the middle of a history that means you stop asking questions and escalate.

Section 1Before You Speak: Preparing for the Interview

Preparing yourself and the room

The interview begins before you enter the room. Review what is already known — the chart, the admission note, the handoff you just received, the medication list, the last set of vital signs, the reason the patient is here. This is the preinteraction phase, and it exists so that you do not spend the patient’s energy asking for data that is already documented. A patient who has told four people in six hours that her mother died of breast cancer will not enjoy telling a fifth. Reviewing first also lets you enter with a hypothesis: if the handoff said “new onset atrial fibrillation,” you already know you will be asking about palpitations, alcohol, thyroid disease, and anticoagulation.

Then prepare the physical space, because environment is technique. Close the door or draw the curtain fully — a curtain that is half open is not privacy, it is theater. Silence or mute the television. Adjust the lighting so the patient can see your face, and position yourself so a light source is not behind you, which turns you into a silhouette. Set the room to a comfortable temperature and offer a blanket; a shivering, half-covered patient is thinking about their body, not your questions. If the patient uses glasses, hearing aids, or dentures, put them in before you begin. Removing the barriers to communication takes ninety seconds and improves the quality of every answer that follows.

Finally, prepare your own attention. Put the phone away or turn it face down. Decide before you start how much time you actually have and tell the patient the truth about it: “I have about fifteen minutes right now, and I want to use it on what matters most to you.” A bounded, honest interview earns more trust than an open-ended one you visibly abandon halfway through. If the patient is in significant pain, nauseated, or urgently needs the bathroom, address that first. Maslow applies to interviewing too — nobody gives a good family history while they need a bedpan.

The phases of the interview

The orientation phase (also called the introduction) is short and it is where credibility is established. Knock, wait, enter. Address the patient by their preferred name and title — ask, do not assume, and never default to “honey,” “sweetie,” or “buddy.” Introduce yourself with name and role: “Good morning, Mr. Alvarez. I’m Dana Whitfield, I’m the registered nurse caring for you until seven tonight.” State the purpose and the plan: “I’d like to ask you some questions about your health so we can plan your care, and then I’ll do a physical assessment.” Ask permission and confirm identity using two identifiers per your facility policy — typically full name and date of birth, checked against the armband, never the room number.

The working phase is the body of the interview: data collection, symptom analysis, and validation. It moves from open to focused. You begin broad (“Tell me what brought you in”), let the patient talk without interruption, then narrow into specific closed questions to fill the gaps (“Has the pain ever woken you from sleep?”). Beginners reverse this order and start firing closed questions, which produces a checklist of yes and no answers and misses the story. Resist the urge. Research on clinician behavior consistently finds that patients are interrupted within roughly eleven to twenty-three seconds of beginning to speak; if you simply stay quiet for sixty to ninety seconds, most patients will hand you the history unprompted.

The termination phase closes the loop. Summarize what you heard in your own words and ask the patient to correct you: “So the pressure in your chest started Tuesday, comes on when you climb stairs, goes away when you rest, and this morning it lasted longer than usual. Did I get that right?” This is not a courtesy — it is error checking, and it routinely catches misunderstandings. Then ask the highest-yield question in all of nursing: “Is there anything else you think I should know?” Tell the patient what happens next and when you will be back. Never end an interview by walking out mid-sentence; if you must leave, name it and give a return time.

Presence, positioning, and the therapeutic use of self

Sit down. A nurse who sits is perceived as having spent substantially more time in the room than a nurse who stands for the identical duration, and the patient discloses more. Sit at the patient’s eye level or slightly below — standing over a supine adult in a bed reproduces a power imbalance that suppresses disclosure. Keep an interpersonal distance of roughly four to five feet, about twice arm’s length, for the conversational portion; that is close enough for warmth and far enough that the patient does not feel cornered. Move into personal and intimate space only for the physical examination, and announce it first: “I’m going to listen to your lungs now, so I’ll be standing close behind you.”

Keep your posture open — uncrossed arms, hands visible, leaning slightly forward, feet toward the patient. Avoid barriers: do not conduct the interview from behind a computer workstation with your back to the bed. If you must chart during the conversation, angle the screen so the patient can see it, and tell them what you are doing: “I’m typing what you said so I get it right.” Eye contact should be comfortable and intermittent, not fixed staring; the culturally appropriate amount varies widely, and in some communities sustained direct eye contact from a younger person to an elder, or across genders, is read as disrespect rather than attentiveness. Follow the patient’s lead.

Therapeutic use of self means deliberately deploying your own presence — voice, pace, face, silence — as an instrument. Speak slightly slower and lower than feels natural. Match your affect roughly to the patient’s: brisk cheerfulness delivered to a frightened person reads as dismissal. Watch your own nonverbals, because patients read them ruthlessly; a nurse who winces at a wound teaches the patient that the wound is disgusting. And protect confidentiality actively, not passively. Under the HIPAA Privacy Rule you must apply reasonable safeguards to limit incidental disclosures, which in practice means you do not take a sexual history through a curtain in a semi-private room. (The separate minimum-necessary standard is about how much information you disclose to any given recipient, not about who can overhear you.) Ask visitors to step out for the sensitive portion — “I ask everyone’s family to step out for a few minutes so I can ask some private questions” — which normalizes the request and, crucially, does not tip off a controlling partner that this patient specifically is being screened.

Section 2Therapeutic Communication: What Opens a Patient Up and What Shuts Them Down

Techniques that open the conversation

Therapeutic communication is a set of named, teachable moves. Open-ended questions invite narrative and cannot be answered with one word: “Tell me about the pain,” “What has your breathing been like at home?” Start here for every new problem. Closed or direct questions pin down specifics and are appropriate later or in an emergency: “Are you allergic to any medication?” “What time did it start?” In a rapid response, closed questions dominate, and that is correct — technique follows acuity.

Silence is the most underused technique in nursing. After a hard question, wait at least three to five seconds. The pause feels enormous to you and normal to the patient, and it is where disclosures live. General leads (“Go on,” “Mm-hm,” “And then?”) keep a narrative moving without steering it. Restating and paraphrasing feed back content so the patient can confirm or correct: “So you stopped the water pill on your own two weeks ago.” Reflection feeds back feeling rather than content: “You sound frightened.” Clarification repairs vagueness — “When you say dizzy, do you mean the room spins, or you feel like you might pass out?” That single clarification separates vertigo from presyncope and changes the entire workup.

Focusing narrows a scattered account (“Let’s stay with the chest pressure for a moment”). Empathy statements name and legitimize the emotion without claiming to share it: “That sounds exhausting,” not “I know exactly how you feel.” Offering self supplies presence without promises: “I’ll sit with you for a few minutes.” Validation confirms that a concern is reasonable. Summarizing ends a segment and checks accuracy. Finally, gentle confrontation surfaces a discrepancy without accusation: “You’re telling me the pain is a two out of ten, and I notice you’re guarding your belly and sweating. Help me understand.”

Responses that close it down

Nontherapeutic responses are usually well-intended, which is exactly why they are hard to unlearn. False reassurance (“Don’t worry, everything will be fine”) ends the conversation and cannot be honored; you do not know that it will be fine. Giving advice substitutes your judgment for the patient’s and blocks problem solving; offer information instead. “Why” questions read as accusation — “Why did you stop taking your insulin?” puts the patient on trial, while “What made it hard to keep taking the insulin?” produces the real answer, which is often that a vial costs more than the electric bill.

Leading and biased questions supply the answer you expect (“You don’t drink much, do you?”) and reliably generate false negatives. Stacked questions — three at once — get one answer and you will not know which. Medical jargon produces polite nodding: patients routinely misinterpret “NPO,” “void,” “hypertension,” and “negative results.” Changing the subject, defensive responses, stereotyped comments (“Everything happens for a reason”), false agreement, and interrupting all communicate the same message: your story is not welcome here. Watch also for distancing language (“the gallbladder in 12B”) and elderspeak — the sing-song, over-loud, diminutive register used with older adults, which is associated with resistance to care and loss of dignity.

Hard conversations: anger, tears, silence, and sensitive topics

An angry patient is usually a frightened or powerless one. Do not match the volume. Keep your voice low and slow, maintain a safe exit path, acknowledge the feeling without conceding facts you do not know (“You’re angry that no one told you about the delay. That’s fair — let me find out what happened”), and set a clear behavioral limit if needed (“I want to help you and I need you to stop shouting so I can hear you”). If you feel unsafe, leave and get help; personal safety precedes data collection, always.

A crying patient does not need to be fixed. Stop talking, offer tissues, stay, and wait. “Take your time” is a complete intervention. Do not rush to the next question and do not leave the room to escape the discomfort. With an anxious patient, shorten sentences, ask one thing at a time, and orient frequently. With a withdrawn or depressed patient, expect long latency — count to five before rephrasing, and use simple open questions with generous pauses.

Sensitive topics — sexual health, substance use, intimate partner violence, incontinence, finances, spiritual distress — require three things: privacy, normalization, and a matter-of-fact tone. Normalize with a preamble: “I ask every patient these questions.” Ask permission: “Is it all right if I ask about your sexual health?” Use the patient’s own words back to them. Ask about behavior, not identity (“Do you have sex with men, women, or both?”), and ask about the specific act rather than assuming from a stated orientation. Keep your face neutral. If a patient declines, document the decline and revisit later — a refusal today is not a refusal forever.

When the barrier is language, hearing, vision, or cognition

For patients with limited English proficiency, use a qualified medical interpreter — in person, by video, or by phone. This is a legal obligation for facilities receiving federal funds under Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act, and it is a safety issue: ad hoc interpreters produce clinically significant errors at several times the rate of trained ones. Do not use family members, and never use a child. Speak to the patient, not the interpreter; use first person (“Where does it hurt?” not “Ask him where it hurts”); use short segments; allow extra time. Document the interpreter’s name or ID number and the modality used. A bilingual nurse must be formally qualified by the facility before interpreting.

For hearing loss, first check that hearing aids are in and working. Face the patient in good light, do not cover your mouth, lower your pitch rather than raising your volume (high frequencies are lost first in presbycusis), rephrase rather than simply repeating louder, and reduce background noise. Do not rely on lip reading — only a minority of English speech sounds are visible on the lips. For patients who are Deaf and use American Sign Language, ASL is a distinct language and a qualified ASL interpreter is required; writing notes is not an equivalent substitute. For vision loss, announce yourself on entering and before touching, describe what you are doing, and orient the patient to the room and call light.

For aphasia, distinguish the two patterns, because the nursing approach differs. In expressive (Broca) aphasia comprehension is relatively intact but output is effortful — give time, allow gestures, use yes/no or pointing questions, and never finish sentences unless the patient asks you to. In receptive (Wernicke) aphasia speech is fluent but the content is off and comprehension is impaired — use short concrete phrases, gestures, pictures, and demonstration. For dementia or delirium, interview in a calm environment, ask one simple question at a time, avoid open-ended abstraction, use closed questions, and obtain collateral history from a caregiver — while still directing questions to the patient first. Document the source and your judgment of reliability.

Section 3The Complete Health History, Component by Component

Biographic data, source, reliability, and the reason for seeking care

Biographic data anchors the record: full legal name, date of birth, age, sex assigned at birth and gender identity, pronouns, address and phone, occupation (present and past), preferred language, marital or partnership status, emergency contact, and insurance or payer if your facility collects it. Occupation is not administrative trivia — a forty-year history of grain dust, asbestos, or solvent exposure explains a chest film, and a night-shift schedule explains a hemoglobin A1c.

Source of history and reliability come next. Record who provided the information: the patient, a parent, a spouse, a group-home staff member, a prior record, or emergency medical services. A primary source is the patient; anything else is a secondary source. Then state whether the account seems reliable, and why. Reliability is not an insult — it is a flag for whoever reads your note next.

The reason for seeking care — historically called the chief complaint, increasingly called the chief concern — is a brief statement, ideally in the patient’s own quoted words, plus a duration. Write “‘My heart’s been flip-flopping since Saturday’ — 3 days,” not “atrial fibrillation.” The patient’s words are data; your diagnostic label is inference, and inference belongs later. Recording a label instead of the words is one of the most common and most consequential documentation errors students make, because it quietly closes the differential before anyone has examined the patient.

History of present illness, past health history, medications, and allergies

The history of present illness (HPI) is the chronological, detailed story of the current problem from the last time the patient felt well to now. It is built by symptom analysis, which Section 4 covers in full. It should include what the patient has already tried, what happened when they tried it, and their own theory of what is wrong — that last item takes ten seconds and frequently reveals the actual reason they came in (“My brother had the exact same thing and it was his heart”).

Past health history covers childhood illnesses; chronic conditions with dates of diagnosis; hospitalizations and surgeries with dates and facilities; injuries and accidents; blood transfusions; immunization status (including influenza, COVID-19, tetanus/Tdap, pneumococcal, shingles, and HPV as age-appropriate); most recent screening tests and examinations; and, for patients who can become pregnant, an obstetric history. Obstetric history is commonly recorded as GTPAL — Gravida (total pregnancies), Term births (37 weeks 0 days or later), Preterm births (20 weeks 0 days through 36 weeks 6 days), Abortions or losses before 20 weeks, and Living children.

Medication reconciliation is a required, high-risk task. Ask the patient to name every prescription, over-the-counter product, vitamin, herbal supplement, inhaler, eye drop, patch, injectable, and “as needed” medication — and ask about each category explicitly, because patients almost never volunteer eye drops, topicals, or supplements when asked “what medications do you take?” For each, capture drug, dose, route, frequency, indication, and when the last dose was actually taken, which is often not what the label says. Ask about sharing or borrowing medications, and ask about cost as a barrier without judgment. The best practice is to have the patient or family bring in the actual bottles.

Allergies require the reaction, not just the name. “Allergic to penicillin” is nearly useless; “Penicillin — hives and lip swelling within 1 hour, age 22, required epinephrine” is actionable, and “Penicillin — upset stomach as a child” describes an intolerance, not an allergy. That distinction changes antibiotic choice and patient outcomes. Ask separately about food, latex, contrast media, tape and adhesives, and environmental allergens. Document severity and the date of the reaction.

Family history and the genogram

Family history looks for heritable and familial risk across at least three generations — the patient, siblings and children, parents, and grandparents. Ask about age and cause of death for deceased relatives and current age and health for living ones. Screen specifically for cardiovascular disease and early sudden cardiac death, hypertension, stroke, diabetes, cancers (with the organ and the age at diagnosis), kidney disease, seizure disorders, mental illness and suicide, substance use disorder, tuberculosis, and known genetic conditions such as sickle cell disease, cystic fibrosis, or hemophilia.

Age at diagnosis is the part students skip and the part that matters most. A father with a myocardial infarction at 78 is unremarkable; a father with a myocardial infarction at 44 is a premature-family-history risk factor that changes lipid management. Breast cancer in a grandmother at 80 is different from breast cancer in a sister at 35, which may prompt genetic counseling. Bilateral, multiple-primary, or male breast cancer, and clusters of breast with ovarian or pancreatic cancer, raise concern for inherited susceptibility.

A genogram is the drawn version of this: squares for males, circles for females, a diamond when sex is unknown, a slash through the symbol for deceased with the age and cause noted, horizontal lines for partnerships, vertical lines for offspring, and the patient marked with an arrow. It compresses three generations into an image you can read in five seconds and is far more useful at a glance than a paragraph. Also ask about family environment and shared exposures — household smoking, water source, occupational exposures, and who the patient can actually call at two in the morning.

Functional assessment and perception of health

Functional assessment asks what the patient can do, not what is wrong with them, and it is what determines whether discharge is safe. Assess activities of daily living (ADLs) — bathing, dressing, toileting, transferring, continence, and feeding — and instrumental activities of daily living (IADLs) — managing medications, managing money, shopping, cooking, housekeeping, laundry, using the telephone, and transportation. Ask about assistive devices, who helps and how often, and what has changed in the last six months. A patient who could climb their porch steps in March and cannot in June has a story worth chasing.

Extend into the domains that predict outcomes: nutrition (a 24-hour dietary recall, appetite change, unintentional weight loss, food access, chewing and swallowing, dentition); elimination patterns; sleep and rest (hours, insomnia, snoring, witnessed apnea, daytime somnolence); activity and exercise; substance use including tobacco, vaping, alcohol, cannabis, and other drugs, quantified honestly (“How many days a week do you have a drink? On those days, how many?”); sexual health; occupational and environmental hazards; coping and stress; social supports; spiritual and cultural practices that affect care; and advance directives and health care proxy.

Screen for social drivers of health deliberately, because they are more predictive of readmission than most laboratory values: housing stability, food security, transportation, utilities, interpersonal safety, literacy, and ability to afford medications. Ask plainly — “In the last twelve months, did you worry that your food would run out before you got money to buy more?” Close the history with the patient’s perception of health: “How would you describe your health? What do you think is going on? What are you hoping we can do?” Self-rated health is a startlingly strong predictor of outcomes, and the answer tells you exactly where to aim your teaching.

Section 4Symptom Analysis, the Review of Systems, and the Bridge to the Physical Exam

Analyzing a symptom: OLDCARTS and PQRSTU

Every symptom — pain, cough, dizziness, nausea, a rash, palpitations, fatigue — gets the same systematic dissection. Two mnemonics dominate. OLDCARTS: Onset (when did it start, sudden or gradual, what were you doing), Location (point to it with one finger), Duration (how long does an episode last, is it constant or intermittent), Characteristics (in your words — sharp, crushing, burning, tearing), Aggravating and associated factors (what makes it worse; what else happens with it), Relieving factors and radiation (what helps; does it travel), Timing and treatment (pattern across the day; what have you already taken), Severity (0 to 10, and what it stops you from doing).

PQRSTU covers the same ground with a different handle: Provocative and palliative, Quality, Region and radiation, Severity, Timing, and Understanding — the patient’s own interpretation and the impact on daily life. Use whichever your program teaches; use it every single time, including at three in the morning, because completeness is what makes the pattern visible. The character of chest pain distinguishes pleuritic from ischemic; the radiation of flank pain to the groin suggests a ureteral stone; a sudden “thunderclap” onset of the worst headache of a person’s life is a subarachnoid hemorrhage until proven otherwise.

Two additions elevate a student history to a professional one. First, always ask what makes it better or worse in behavioral terms — not just “does anything help” but “does leaning forward help, does eating make it worse, does it wake you at night.” Second, always capture pertinent negatives: the symptoms you deliberately asked about and the patient denies. “Denies fever, cough, hemoptysis, leg swelling, or recent travel” in a patient with chest pain proves you thought about pneumonia and pulmonary embolism. Absent findings, documented, are evidence of clinical reasoning.

The review of systems

The review of systems (ROS) is a head-to-toe screen of subjective symptoms, by body system, to catch problems the patient did not think to mention. It is entirely questions — nothing you observe belongs here. Move in a fixed order so you do not skip a system: general, integumentary, head and neck, eyes, ears, nose and sinuses, mouth and throat, respiratory, cardiovascular, peripheral vascular, gastrointestinal, genitourinary, sexual and reproductive, musculoskeletal, neurologic, hematologic, endocrine, and psychiatric.

Use plain language. Ask “Any trouble swallowing?” not “Any dysphagia?” Ask “Do you ever leak urine when you cough or laugh?” rather than “Any stress incontinence?” A complete ROS is appropriate for a comprehensive admission history; for a focused or emergency assessment, review the system involved plus the systems immediately adjacent to it. Whichever you do, document which it was — “Focused ROS, cardiopulmonary” is honest; implying a complete ROS you did not perform is a documentation integrity problem.

Certain ROS answers are not merely positive — they are stop-signs. Learn them as a set, because they arrive in the middle of an otherwise routine conversation and your job is to recognize them in real time.

Subjective, objective, and the handoff to the physical examination

Subjective data is what the patient (or a proxy) reports — symptoms, feelings, perceptions, history. It cannot be observed by anyone else and is documented as reported: “Pt reports…”, “Pt states…”, “Pt denies…”, or in direct quotation. Objective data is what you observe, measure, or elicit — vital signs, a wound’s dimensions, lung sounds, a laboratory value, an observed limp. Nausea is subjective; emesis of 200 mL of coffee-ground fluid is objective. Pain is uniquely both: the reported score is subjective and is charted as the patient states it, while guarding, grimacing, tachycardia, and diaphoresis are objective corroboration. You never override a reported pain score with your own impression.

When the history is complete, you move to the physical examination, and the sequence there is fixed: inspection, palpation, percussion, auscultation. Inspect first because touching changes what you will see and because looking costs nothing. Palpate second, light before deep, warm hands, painful areas last. Percuss third to assess density and organ borders. Auscultate fourth. Work in an organized head-to-toe order, compare side to side for symmetry, and expose only the region being examined.

There is exactly one region where this order changes, and you must know it cold. For the abdomen, the sequence is inspect, auscultate, percuss, palpate. Auscultation moves ahead of percussion and palpation because manipulating the abdominal wall alters bowel motility and therefore falsifies the bowel sounds you are about to grade. Listen before you touch, in all four quadrants, before percussing or palpating anything. Examine any area the patient identifies as painful last, and stop deep palpation entirely if there is rigidity, rebound, or a known or suspected abdominal aortic aneurysm.

The history also tells you what to expect from the vital signs and how hard to worry when they deviate. Know the adult numbers exactly, and know how they shift across the lifespan, because “a heart rate of 130” is a red flag in an adult that demands an immediate search for a cause, and is unremarkable in a well six-month-old.

Adult oral temperature normally runs 36.5–37.5 °C (97.7–99.5 °F); rectal readings average about 0.5 °C higher and axillary about 0.5 °C lower. Fever in an adult is generally defined at 38.0 °C (100.4 °F) or above. Older adults run a lower baseline, often 35.8–36.6 °C, and may mount no fever at all with serious infection — a single oral temperature of 37.8 °C (100 °F), repeated readings above 37.2 °C (99 °F), or a rise of 1.1 °C (2 °F) over that patient’s own baseline should be treated as fever. Oxygen saturation is 95–100 percent on room air for most adults; patients with chronic carbon-dioxide retention are often targeted to 88–92 percent, so know the ordered target before you adjust anything. Be aware that pulse oximeters can overestimate true arterial saturation in patients with darker skin pigmentation, producing occult hypoxemia — a normal-looking reading in a patient who is genuinely hypoxic. Never let the number override the patient: work of breathing, respiratory rate, mental status, and the patient’s own report of breathlessness come first, and a reading that does not match the patient warrants a repeat on a different site and escalation.

Section 5Lifespan, Culture, Risk Screening, Charting, and Escalation

Adapting across the lifespan

For infants, the history comes entirely from the caregiver and includes prenatal, birth, and neonatal history — gestational age, complications, delivery mode, birth weight, newborn screening, feeding method and volumes, wet diapers per day, sleep position, and developmental milestones. Perform the least invasive parts of any assessment while the infant is calm and in the caregiver’s arms.

Toddlers and preschoolers think concretely and magically; they may believe illness is punishment. Get to eye level, use short words, allow a security object, and offer limited real choices (“left arm or right arm?” — never “may I?” for something that is not optional). Avoid frightening literalisms: “take your blood pressure” and “shot” and “put you to sleep” are heard exactly as spoken. School-age children can give substantial history themselves and want a mechanical explanation; ask them first, then verify with the caregiver.

Adolescents must be given time alone with the clinician. Explain confidentiality and its legal limits up front — you will keep what they say private except where there is risk of harm to themselves or others, or abuse. Use the HEEADSSS framework: Home, Education and employment, Eating, Activities, Drugs, Sexuality, Suicide and depression, and Safety, moving from least to most sensitive. In pregnancy, add GTPAL, prenatal care, fetal movement, and the preeclampsia symptom set. For older adults, allow more time, ask about function and falls, review polypharmacy and who fills the pillbox, screen for cognition and mood, and ask about caregiver strain and elder mistreatment — privately. Do not shout; do not use elderspeak; do not assume confusion until you have ruled out hearing loss, delirium, pain, and hypoxia.

Cultural humility, and findings across skin tones

Cultural humility is a posture, not a body of memorized facts: you assume you do not know this patient’s beliefs and you ask. Useful questions include “What do you think caused this?”, “What do you call it?”, “What have you already tried, including home or traditional remedies?”, and “Who in your family helps make health decisions?” Ask about fasting, dietary law, modesty and same-gender caregiver preferences, and practices around touch, blood products, and end of life. Never generalize from an ethnic label to an individual’s beliefs.

Skin tone changes how findings appear, and describing every abnormality as “redness” is both inaccurate and a documented source of missed pressure injuries and missed hypoxia in patients with darker skin. Assess in natural or bright white light, compare with the patient’s own baseline and adjacent skin, and always use the mucous membranes and palms as a check.

Screening for risk, and the red flags that stop the interview

Several validated screens belong in the history. The PHQ-2 asks about depressed mood and anhedonia over two weeks; a score of 3 or more is positive and should be followed by the PHQ-9. Any positive response to item 9 of the PHQ-9, or any spontaneous statement about wanting to die, triggers a direct suicide risk assessment — ask plainly (“Are you having thoughts of killing yourself?”), then ask about plan, means, timeline, and intent. Asking does not plant the idea; the evidence is clear on this. AUDIT-C screens alcohol use (positive at 4 or more for men, 3 or more for women); the CAGE questionnaire is positive at 2 or more. Screen for intimate partner violence privately, with the partner out of the room, using a brief tool such as HITS, and know your state’s mandatory reporting law for children, dependent adults, and elders.

Some statements end the data-collection phase immediately. Recognize them and act: chest pressure with diaphoresis, dyspnea, or radiation to the jaw or arm; sudden severe headache described as the worst of the patient’s life; new facial droop, one-sided weakness, or speech change (get the last-known-well time before anything else); airway symptoms after a new medication — lip or tongue swelling, throat tightness, stridor, hives; hematemesis, melena, or syncope; suicidal or homicidal ideation with plan or means; disclosure of abuse with immediate danger; and any patient who says they feel a sense of impending doom — which is a genuine clinical sign, not an anxiety symptom, until you have proven otherwise. One tier below these, but still requiring that you notify the provider before the shift moves on rather than charting it and continuing, is a missed dose of insulin, anticoagulant, antiepileptic, or antirejection medication.

Charting the history and escalating with SBAR

Documentation of a history has four requirements: it is timely, objective in tone, specific in measurement, and attributed to a source. Quote the patient for the reason for seeking care and for anything clinically or legally significant. Use “reports,” “states,” and “denies” rather than “complains of,” which reads as judgment. Never chart opinion about character (“drug seeking,” “uncooperative,” “poor historian”); chart the behavior you observed instead. Never chart care before it is given, never chart for another person, and correct errors according to policy — single line, initial, date, addendum — never by erasing or deleting.

When you escalate, use SBAR, and have the chart, the last vital signs, and the medication list in front of you before you dial. Situation: “This is Dana Whitfield, RN, on 4 East calling about Mr. Alvarez in room 412. He has new chest pressure that started 30 minutes ago.” Background: “He’s a 62-year-old admitted yesterday for cellulitis, with a history of type 2 diabetes, hypertension, and a father who died of a myocardial infarction at 51. He’s on metformin and lisinopril, no anticoagulation.” Assessment: “Blood pressure 148/92, heart rate 104 and regular, respirations 24, oxygen saturation 94 percent on room air, temperature 36.8. He’s diaphoretic and describes 7 out of 10 pressure radiating to his jaw. I think this is cardiac.” Recommendation: “I’d like a 12-lead ECG now, cardiac markers, and an order for aspirin. Can you come see him, or should I activate rapid response?” Then read back any orders you receive, and document the call with the time, the person notified, and the response.

Delegation and scope

Interviewing is a professional nursing act. The registered nurse performs the initial and ongoing assessment, analyzes the data, formulates nursing diagnoses, teaches, evaluates responses to interventions, and manages unstable patients. None of that may be delegated. In particular, the health history, the interpretation of a symptom, the suicide risk assessment, patient education, and any judgment about reliability or acuity stay with the RN. Delegation follows the five rights — right task, right circumstance, right person, right direction and communication, right supervision and evaluation — and the RN who delegates retains accountability for the outcome.

Unlicensed assistive personnel may perform standardized, predictable tasks on stable patients: obtaining and recording routine vital signs, height and weight, intake and output, capillary blood glucose where policy allows, bathing, feeding, ambulating, and positioning. UAP may — and should — report what a patient told them, and you should ask them what they noticed; their observations are valuable raw data that you then interpret. What UAP may not do is collect the history, decide what a symptom means, teach the patient, evaluate the effect of an intervention, or take vital signs on an unstable patient whose readings will drive an immediate decision. Give explicit parameters when you delegate: “Please take Mr. Alvarez’s vital signs now and tell me right away if his heart rate is over 110, his systolic is under 100, or his oxygen saturation is under 92.” A licensed practical or vocational nurse can gather focused data and reinforce teaching within state scope, but the comprehensive assessment and the care plan remain the RN’s.

Words worth knowing