Nursing Component Task
Nursing procedures & clinical learning

Registered Mental Health Nursing (RMN)

HISTORY TAKING OF A PSYCHIATRIC PATIENT

This is the process of gathering information about a patient’s physical, mental and social state. These pieces of information could be obtained from the patient, relative(s) or significant others.

Purpose

  • Gain a better understanding of patient’s problem
  • Obtain useful information in formulating a nursing diagnosis
  • Provide effective nursing care to the patient
  • Give treatment

Equipment

  • Table
  • Chair
  • Pen and paper
  • Patient’s folder (Electronic/Manual)
  • Vital signs tray
  • Weighing scale/ Stadiometer
  • Serene environment

Procedure steps

  • Welcome patient and relative(s) and offer them seat(s)
  • Sit near them with electronic device/writing material
  • Establish rapport (refer procedure) and explain procedure
  • Initiate communication with patient and relative(s) with assurance of confidentiality
  • Establish eye contact with patient during history taking
  • Observe patient’s behaviour and reactions
  • Obtain information highlighting on the following:
  • Demographic/Personal history – name, age, sex, address, occupation etc.
  • Present psychiatric history – presenting complaints, onset, duration, etc. .
  • Past psychiatric history – previous episodes, treatments, duration, etc.
  • Family history – family genogram (medical, surgical, psychiatric conditions, etc.)
  • Developmental history – pre-natal, developmental milestone, malnutrition etc.
  • Pre-morbid personality – mood, hobbies, habits etc.
  • Assess patient’s current mental state
  • Check and record the vital signs of the patient
  • Measure the weight and height of patient and record
  • Summarize the salient points and allow patient/relative(s) to ask questions
  • Close the session
  • Express appreciation to patient and relative(s) and inform them on what to do next
  • Document findings in the nurses’ note/patient’s folder

References and further reading

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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