Taking a history and making a functional assessment

wpid-patient-history.jpg

 During a clinical assessment, a patient’s history can be the key to helping an OH professional decide if someone is fit for work or not. Greta Thornbory explains how best to conduct the process.

Taking a patient’s history has traditionally been regarded as the domain of their doctor. However, since the introduction of the “nursing process” in the 1970s by the Department of Health, which includes the assessment of patients, the nurse has been required to obtain some sort of patient history as well as their experiences, any signs and symptoms and current health status (Fawcett and Rhymnas, 2012).

Box 1: Establishing the reason for referral

When a patient first presents, OH nurses should find out:

  • the presenting situation;
  • the history of the situation;
  • a systemic enquiry;
  • past medical history;
  • any drug use and allergies;
  • social and personal history;
  • family history; and
  • the patient’s ideas, concerns and expectations around the referral.

In OH, taking a history is an essential part of an OH nurse’s work. Nurses often find they are having to start from scratch with new employees and management referrals, particularly if they are working for an OH provider where the workforce is not known. This article explores how OH nurses should go about taking a history and making a functional assessment.

As “taking a history” is not part of nurses’ initial training, it is a new skill that has to be learnt on the job. It is needed to make an accurate assessment of the situation and to answer the question: “Is this person fit to undertake their work?”

This is different to the doctor’s role when taking a history. Along with examination and investigations, the doctor has to arrive at a clinical diagnosis. The ability to make an assessment of people’s health, collect, collate and report data and information are all part of an OH nurse’s competencies (Royal College of Nursing, 2011).

The OH nurse then has to prepare a suitable report advising management of fitness or otherwise of the client without breaching confidentiality, unless the client has signed a disclosure agreement.

Fawcett and Rhymnas suggest that history taking in its simplest form involves asking appropriate questions to obtain clinical information. Medical textbooks (Washer, 2009)say that there is no single and correct way to take a history and suggest the sequence outlined in box 1, although not all of the steps will be necessary for an OH assessment.

Communication

For nurses, some of the essential skills, such as communication, are part and parcel of everyday practice and do not require much of an investment to maintain. Shah (2005) says that communication skills are particularly important when opening and closing a consultation and that, when taking a history, care should be taken with:

  • questioning and the use of open and closed questions;
  • non-verbal language;
  • active listening;
  • showing respect and courtesy;
  • showing empathy; and
  • being culturally sensitive.

In OH it is important to introduce yourself in a warm and friendly manner and to make your client feel at ease, particularly when they may have been referred to OH to establish whether or not there is a health reason for frequent absence.

New employees are keen to get the job and employees referred by management maybe very apprehensive. Those of us who have been in OH for a number of years accept that our profession is not always well understood, and the first few minutes of a consultation may well be taken up with explaining the reasons for the appointment and allaying fears and anxieties.

It is then useful to obtain some background information on the person, including their full name – to avoid confusion with others of the same or similar name – and their age, date of birth and occupation. Following recent legislation, people are concerned about asking someone’s age as they believe it is unlawful. This is incorrect – the Equality Act 2010 prevents “discrimination” against someone on the ground of age.

Taking notes

When taking a history, it is necessary to make notes – but these should be brief, not an essay. Ensure each sheet of paper used has the patient’s name on it and that every separate entry you make is dated and signed. It is also a good idea to add your name to the document for the purposes of identification.

Patient notes are a legal document and it helps if they are legible. There will be times where you want to quote exactly what the individual says, but the whole interview should not be a dictation session.

If used, abbreviations must be intelligible to anyone who might need to read your notes – for example, a lawyer years after you have left the post.

If you have a good memory and lots of time, you can write up your notes after the employee leaves. The usual practice is to jot down notes as you go along, unless there is a need to show that you are listening intently to a sensitive matter.

Electronic records

There is a move towards keeping patient notes and records electronically. If this is what you do, make sure there are checks and balances in place to ensure security and to enable an audit trail to be followed. For those with both electronic and paper formats, there is a system where the paper notes are stamped with “information held on (name of computer programme)”.

Box 2: The activities of daily living

  • Maintaining a safe environment.
  • Communicating.
  • Breathing.
  • Eating and drinking.
  • Eliminating.
  • Personal cleansing and dressing.
  • Controlling body temperature.
  • Mobilising.
  • Working and playing.
  • Expressing sexuality.
  • Sleeping.
  • Dying.

It is important to check that any new electronic system has the necessary security and ease of use to ensure that there is an audit trail to follow, especially where notes are made directly on screen. This should be discussed with the company supplying the software.

Presenting situation

First, establish why the person is in front of you. This should be clear if there is a proper management referral system in place that ensures the employee has signed their agreement to the referral. A template referral form is given in “Employment Law and Occupational Health: A Practical Handbook” (Lewis and Thornbory, 2010).

Listen carefully to what the patient has to say and encourage them to continue the story right up to the present day. Record details of the patient’s own words, not just what you think they said.

History of the situation

You then need to note down what they have said and get it in chronological order. You may need to clarify at times, such as when the patient says they had flu and whether it was actually flu or just a cold.

Establish what investigations and treatment were given and what the person had been told by their GP or specialist. Do not forget to ask about what medicines, either prescribed or over the counter, they are taking. Beware of asking what drugs they are taking as this may be misconstrued as meaning illegal drugs – it is better to ask what medication they are taking.

Functional assessment

If the person is referred to you for assessment of their ability to undertake certain tasks, it is worth considering the five steps of disability analysis (Ellis, 2008):

1. The functional history considers what the individual is capable of and not what they are incapable of. Take a positive approach.

2. Observe what you can see the patient is capable of doing.

3. Conduct a focused examination of the patient’s physical problems, if necessary.

4. Consider all available evidence, including GP and specialist opinions where necessary, in a logical reasoning of evidence.

5. Justify your opinions based on the evidence of all the above.

The prime objective for the disability analyst in this process is not to diagnose and treat, but to assess the functional effects of a person’s condition on day-to-day living.

In disability analysis, history taking focuses on day-to-day living rather than on a clinical history, although basic clinical information is still needed. The precise diagnosis is not critical.

In terms of the impact on daily life, it is the functional effects of the condition that are more important. We obtain a functional history based on the individual’s day-to-day activities and any difficulties or restrictions that they have with those actions.

That history focuses on an in-depth account of the person’s normal activities including interests, hobbies, household chores, shopping, cooking, social activities and holidays.

We call this the “typical day” approach. This approach is a very useful method of obtaining information about the individual’s regular activities and habits.

It moves away from the clinical focus where we find out about the symptoms and signs related to a particular illness.

Although we use the term “typical day”, we do not limit the history to a single day, but also refer to less frequent activities occurring weekly, monthly or sometimes even annually.

For OH nurses it may also be useful to consider the “activities of daily living” as described by Roper, Tierney and Logan (1980), on which their model of nursing is based (see box 2).

When assessing people, it is important to use good listening techniques. Remember that appropriate eye contact and suitable body language leave a lasting impression – use clear, familiar and understandable language and show interest in the individual.

Allow the patient to express their needs as fully as possible and always explain what is being done throughout the assessment.

During the assessment, remember to summarise, review and clarify – note the manner in which something is said as well as what was said. Try to use an open questioning style, using closed questions to clarify facts or to redirect the interview. Also use positive body language throughout the assessment.

Observed behaviour is quite important. The observation process starts as soon as you meet the individual. For example, information could be gathered on the patient’s ability to hear when their name is called in the reception area.

Further observation could provide evidence about other areas such as lower-limb function when rising from a chair and walking to the consulting room, upper-limb function when the patient is carrying a bag or whether or not they have any difficulties opening doors, and other areas of functional ability.

The aim here is to give reasoned advice by using knowledge of the history and effects of the conditions present in order to predict the likely effects on the individual’s functional ability.

Box 3: Key assessment points

  • Listen carefully and give the person your undivided attention.
  • Make minimal notes while your patient is talking.
  • Do not use medical jargon or abbreviations, but clarify in plain English that is easy to understand.
  • Keep patients on track with their story, but let them tell it in their own way.
  • Use open questions – such as what, when, where and how – and avoid leading questions.
  • Reflect back to your patient/client using a summary to check your understanding of what they have told you.
  • Invite the person to correct any inaccuracies.

Let us consider the example in case study below (see box 5). There are several different ways to model disability and the main one used today is the biopsychosocial model (Waddell and Burton, 2004).

This model reconciles and extends beyond the medical and social models, taking into account biological, mental health issues and social factors, and therefore encourages a holistic approach.

You may find it useful to use the format outlined in “Tackling Musculoskeletal Problems: A Guide for Clinic and Workplace” (Kendall and Burton, 2009).

If there is a suspicion that this may be a work-related illness, additional information is required, such as a full job description and whether or not others have reported similar signs and symptoms.

Taking an occupational history to establish exposure is essential, and it may be necessary to go back over several years.

It is prudent to mention here that one should not label anything as “work related” until this has been thoroughly investigated and established by a medical opinion.

Systemic enquiry and past medical history

Now that you have explored the current situation, ask about any previous illness if you believe it may be relevant. Remember that the Data Protection Act 1998, since subsumed into the Equality Act 2010, requires that only absolutely necessary information is obtained and kept.

If it is necessary to explore further with in-depth questions, then use the checklist in box 3 and box 4. Remember to always use words that your patient will understand and not medical terminology or jargon.

Asking a woman if she suffers from menstrual difficulties or dysmenorrhoea may result in the wrong answer, so it is better to use commonly accepted terminology such as irregular periods or period pains – and only if it is relevant.

Drugs and allergies

Depending on where the person is working, asking about drugs and allergies may be very relevant, so it is important to know details about the person’s job, area of work and to have been given copies of the latest job risk assessment and job description.

Accurate assessment of suitability for a job or continuing to work cannot be made if this information is not available.

Smoking and alcohol misuse

Unless these have a bearing on the workplace, this information is not necessary to obtain.

Few people will admit to having an alcohol problem, and what one does outside of the workplace is not necessarily relevant. Only when it is a safety critical aspect of the job are drug and alcohol testing required, and in these cases there should be agreed company policies and procedures in place for dealing with the information needed, sampling and chain of custody, the results and so on.

Family history

Is this relevant to OH practice? Is it necessary to gather this information or is it not essential, bearing in mind the Data Protection Act and Human Rights Act?

In most cases, this information is not strictly relevant to OH practice and could be regarded by the patient as invading their personal and family life.

Social and personal history

Bearing in mind the Data Protection Act and Human Rights Act, there is a limit as to how much one can ask about a patient’s social history and it should be kept to only what is relevant to the employment of the person. Knowing about social activities may be extremely relevant when dealing with sickness absence referrals.

It would be best to approach this area with caution and use such phrases as: “In order for me to get a fuller picture, I need to ask you some questions about what you do with yourself when you are not working” or, “If you don’t mind, I would like to ask you some questions about your hobbies and leisure interests.”

Patient ideas, concerns and expectations

Before closing the consultation, it is good practice to ask if the patient has any questions or wants to tell you anything else.

This will give the patient time to express any concerns they have about what you are going to do with the information, reassure them of confidentiality and to encourage them to give their written consent for disclosure where appropriate.

It is also advisable to inform the patient of their rights under the Access to Medical Reports Act 1988, which enables a patient to see and have a copy of their report before it is sent to HR or the employee’s manager.

Lewis (2010) says that there are implications for employees to consider should they unreasonably refuse to consent to the release of a report.

Conclusion

At the close of the assessment, you should give a short summary of what the patient has told you, how you have interpreted this in the context of the workplace and what you will do next. You may wish to include a time frame.

Finally, before the patient leaves it is polite to thank them for coming and for their cooperation.

Greta Thornbory is professional development director for the Association of Occupational Health Nurse Practitioners (UK) and an OH nurse.

References

Fawcett T, Rhymnas S (2012). “Taking a patient history: The role of the nurse”. Nursing Standard; vol.26, issue 24, pp.41-46.

Royal College of Nursing (2011). “Occupational health nursing: career and competency development”.

Washer P (2009). Clinical Communication Skills. Oxford: Oxford University Press.

Nayankumar S (2005). “Taking a history: Introduction and the presenting complaint”. Student BMJ; vol.13, pp.309-352.

Equality Act 2010.

Lewis J, Thornbory G (2010). Employment Law and Occupational Health: A Practical Handbook. Oxford: Blackwell Publishing.

Ellis P (2008). “Disability assessment”. Occupational Health; vol.60, issue 7, pp.38-39.

Roper N, Logan W, Tierney A (1980). The Elements of Nursing. Edinburgh: Churchill Livingstone.

Waddell G, Burton K (2004). Concepts of Rehabilitation for the Management of Common Health Problems. London: TSO.

Kendall NA, Burton K (2009). Tackling Musculoskeletal Problems: A Guide for Clinic and Workplace. London: TSO.

Data Protection Act 1998.

Human Rights Act 1998.

Access to Medical Reports Act 1988.

Box 4: Systemic enquiry

General

  • Fatigue.
  • Loss of appetite.
  • Mood changes.
  • Changes in appearance.
  • Intolerance to hot/cold.
  • Weight change.
  • Skin problems such as rashes or itching.

Locomotor system

  • Pain.
  • Stiffness.
  • Immobility.
  • Swelling.
  • Loss of function.

Cardiorespiratory

  • Chest pain.
  • Breathlessness.
  • Palpitations.
  • Cough.
  • Wheeze.
  • Eyes and ears.

Gastrointestinal

  • Swallowing difficulties.
  • Nausea and/or vomiting.
  • Heartburn or indigestion.
  • Abdominal pain.
  • Bowel habits.

Genitourinary, including gynaecology

  • Dysuria.
  • Frequency of micturition.
  • Changes in urine.
  • Prostatic problems.
  • Menstrual difficulties.

Central nervous system

  • Headaches.
  • Dizzy turns.
  • Fits, faints or “funny turns”.
  • Visual or speech disturbances.

Psychological assessment

  • Emotional reactions during history taking.

Box 5: Case study

A 45-year-old man has a 12-month history of back pain and sciatica, found to be caused by a prolapsed intervertebral disc. A functional analysis would include the following four steps:

1. A history of the back pain, any treatments and the effect on employment. Other effects on daily living should be discussed.

2. The OH professional should make an observation of movements seen informally and formally.

3. Logical reasoning should be used to assess all evidence.

4. A justified opinion should then be given based on the evidence and the patient’s explanations.

Comments are closed.