NU566 Unit 2 The Patient Interview

NU566 Unit 2 The Patient Interview

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Purdue University Global

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

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Date

NU556 Unit 2: The Patient Interview – A Complete Guide to Conducting a Comprehensive Health History

A patient interview is the first and most important step in the clinical assessment process because it provides the subjective information needed to make accurate diagnoses and develop effective treatment plans. A well-structured interview helps healthcare providers identify health concerns, establish therapeutic relationships, improve patient safety, and guide evidence-based clinical decision-making. By following a systematic approach—from obtaining the chief complaint to completing the review of systems (ROS)—clinicians can gather comprehensive information while ensuring patients feel respected, understood, and actively involved in their care.

Whether you are a nurse practitioner, advanced practice registered nurse (APRN), or nursing student completing NU556 Unit 2, mastering patient interviewing skills is essential for delivering patient-centered healthcare.

Preparing for the Patient Interview

Preparation begins before asking the first clinical question. Creating a comfortable, private, and distraction-free environment encourages patients to communicate openly and honestly. Professional introductions and identity verification also promote patient safety while establishing trust.

During the introduction, healthcare providers should:

• Introduce themselves by name and professional role.

• Ask how the patient prefers to be addressed.

• Confirm the patient’s preferred pronouns.

• Verify the patient’s full name and date of birth.

• Explain their role during today’s visit.

• Ensure privacy and maintain confidentiality.

• Use open body language and maintain appropriate eye contact.

Building rapport early increases patient engagement and often results in more accurate and complete health information.

Understanding the Chief Complaint (CC)

The Chief Complaint (CC) is the patient’s primary reason for seeking medical care. It is usually documented using the patient’s own words whenever possible and should remain concise.

Common chief complaints include:

• Chest pain

• Shortness of breath

• Persistent cough

• Headache

• Abdominal pain

• Fever

• Back pain

Helpful opening questions include:

• Why are you here today?

• What brings you in today?

• What concerns you the most?

• How have you been feeling recently?

The chief complaint establishes the focus for the remainder of the clinical interview.

Obtaining the History of Present Illness (HPI)

The History of Present Illness (HPI) provides a detailed description of the patient’s current health concern. It explores symptom development, progression, associated findings, and previous treatment attempts.

One of the most widely accepted methods for documenting the HPI is the OLD CARTS framework.

O – Onset

Determine when symptoms first appeared.

Questions may include:

• When did your symptoms begin?

• Did they start suddenly or gradually?

• Are you still experiencing the symptoms?

L – Location

Identify exactly where the symptom occurs.

Examples include:

• Where do you feel the pain?

• Does it radiate anywhere else?

D – Duration

Determine symptom frequency and length.

Ask questions such as:

• How long does each episode last?

• Are the symptoms constant or intermittent?

• Have they become worse over time?

C – Characteristics

Ask patients to describe their symptoms in their own words.

Common descriptions include:

• Sharp

• Dull

• Burning

• Aching

• Throbbing

• Pressure

• Stabbing

A – Aggravating Factors

Identify activities or conditions that worsen symptoms.

Examples include:

• Walking

• Exercise

• Eating

• Movement

• Stress

• Position changes

R – Relieving Factors

Determine what improves symptoms.

Patients may report relief from:

• Rest

• Medication

• Heat therapy

• Ice

• Position changes

T – Treatments

Review previous interventions.

Ask about:

• Prescription medications

• Over-the-counter medications

• Home remedies

• Physical therapy

• Previous medical evaluations

Also document:

• Medication name

• Dosage

• Frequency

• Effectiveness

S – Severity

Evaluate symptom intensity using standardized scales.

A commonly used question is:

“On a scale of 0 to 10, with 10 being the worst pain imaginable, how severe is your pain?”

Using OLD CARTS helps ensure no essential clinical details are overlooked while improving documentation consistency.

NU566 Unit 2 The Patient Interview

Completing a Comprehensive Medication History

Medication reconciliation is a critical component of every patient interview because medication errors remain a leading cause of preventable adverse events.

Healthcare providers should document:

• Prescription medications

• Over-the-counter medications

• Vitamins

• Herbal products

• Dietary supplements

• Recently discontinued medications

Record:

• Medication name

• Dosage

• Route

• Frequency

• Indication

• Patient adherence

Example question:

“Can you tell me everything you currently take, including vitamins or herbal supplements?”

Performing an Allergy Assessment

Allergy documentation helps prevent adverse drug reactions and improves patient safety.

Ask patients about:

• Medication allergies

• Food allergies

• Environmental allergies

• Latex allergy

• Previous vaccine reactions

Always clarify the reaction experienced, such as:

• Rash

• Hives

• Swelling

• Difficulty breathing

• Gastrointestinal symptoms

• Anaphylaxis

Helpful questions include:

• Are you allergic to any medications?

• What happens when you’re exposed?

• Have you ever experienced a severe allergic reaction?

Reviewing the Past Medical History

Past medical history provides context that may influence diagnosis and treatment planning.

Review chronic illnesses including:

• Hypertension

• Diabetes mellitus

• Asthma

• Coronary artery disease

• Chronic kidney disease

• Cancer

• Mental health disorders

Additional information should include:

• Childhood illnesses

• Pregnancy history

• Previous diagnostic testing

• Significant infectious diseases

Example questions:

• Have you ever been diagnosed with any chronic medical conditions?

• Have you experienced any serious illnesses in the past?

Documenting Surgical History and Hospitalizations

Previous surgeries and hospital admissions often affect current clinical management.

Document:

• Surgical procedures

• Approximate dates

• Hospital admissions

• Reasons for hospitalization

• Surgical or postoperative complications

Example question:

“Have you ever had surgery or stayed overnight in a hospital?”

Collecting Family History

Family history identifies hereditary diseases and inherited risk factors.

Assess whether close relatives have experienced:

• Heart disease

• Hypertension

• Diabetes

• Stroke

• Cancer

• Mental illness

• Thyroid disorders

• Autoimmune diseases

Questions may include:

• Are your parents living?

• Do your siblings have any medical conditions?

• Does your family have a history of cancer or heart disease?

Assessing Social History

A patient’s lifestyle often influences both disease risk and treatment outcomes.

Important areas include:

• Education

• Employment

• Living situation

• Relationship status

• Diet and nutrition

• Physical activity

• Tobacco use

• Alcohol consumption

• Recreational drug use

• Sexual history

• Home safety

• Exposure to violence

Example questions include:

• What type of work do you do?

• Do you currently smoke or vape?

• How often do you drink alcohol?

• Do you feel safe at home?

If tobacco use is identified, document:

• Years smoked

• Packs per day

• Total pack-years

• Previous quit attempts

Evaluating Preventive Health History

Preventive care reduces disease burden through early detection and immunization.

Assess whether patients are current with recommended screenings, including:

• Adult immunizations

• Influenza vaccine

• COVID-19 vaccination

• Pap smear

• Mammography

• Colonoscopy

• Prostate screening

• Bone density testing

• Testicular self-examination

• Breast self-awareness

Questions may include:

• Are your vaccinations up to date?

• When was your last mammogram?

• Have you ever had a colonoscopy?

Completing the Review of Systems (ROS)

The Review of Systems (ROS) is a systematic head-to-toe assessment used to identify symptoms affecting each major body system, including concerns unrelated to the chief complaint.

General

Assess:

• Fever

• Chills

• Fatigue

• Weight changes

• Night sweats

• Appetite changes

Skin

Review:

• Rash

• Bruising

• Wounds

• Color changes

• Changes in moles

Eyes

Assess:

• Vision changes

• Blurred vision

• Eye pain

• Corrective lens use

Ears

Review:

• Hearing loss

• Ear pain

• Ringing in the ears

• Ear drainage

Nose, Mouth, and Throat

Evaluate:

• Nasal congestion

• Nosebleeds

• Difficulty swallowing

• Sore throat

• Hoarseness

• Dental problems

Breast

Assess:

• Breast pain

• Lumps

• Skin changes

• Nipple discharge

Hematologic, Lymphatic, and Endocrine

Review:

• Swollen lymph nodes

• Easy bruising

• Blood transfusions

• Excessive thirst

• Heat or cold intolerance

• Appetite changes

Cardiovascular

Assess:

• Chest pain

• Palpitations

• Edema

• Orthopnea

• Paroxysmal nocturnal dyspnea

Respiratory

Review:

• Cough

• Wheezing

• Shortness of breath

• Hemoptysis

• History of tuberculosis

• Pneumonia

Gastrointestinal

Assess:

• Abdominal pain

• Nausea

• Vomiting

• Constipation

• Diarrhea

• Black or bloody stools

• Hepatitis history

Genitourinary and Reproductive

Review:

• Dysuria

• Frequency

• Urgency

• Sexual activity

• Sexually transmitted infections

• Contraceptive use

For female patients:

• Last menstrual period

• Pregnancy history

• Pap smear

• Mammogram

• Vaginal discharge

For male patients:

• Prostate symptoms

• PSA testing

• Urinary changes

Musculoskeletal

Assess:

• Joint pain

• Joint swelling

• Muscle weakness

• Back pain

• Osteoporosis

• Fractures

Neurological

Review:

• Headaches

• Dizziness

• Weakness

• Numbness

• Seizures

• Syncope

• Paralysis

Psychiatric

Assess:

• Depression

• Anxiety

• Sleep disturbances

• Mood disorders

• Suicidal ideation

• Previous psychiatric diagnoses

Transitioning to the Physical Examination

Once the health history is complete, clearly explain the next step before beginning the physical examination.

A professional transition statement might be:

“Thank you for answering my questions. Next, I’ll perform your physical examination to gather additional information about your health.”

Providing clear explanations helps reduce patient anxiety, improves cooperation, and supports a positive healthcare experience.

Best Practices for Conducting an Effective Patient Interview

Healthcare professionals can improve interview quality by following several evidence-based communication strategies.

Key recommendations include:

• Use open-ended questions before narrowing the discussion.

• Practice active listening without interrupting the patient.

• Maintain empathy and professional communication.

• Avoid medical jargon whenever possible.

• Summarize important information for accuracy.

• Confirm patient understanding using teach-back techniques.

• Document findings immediately and accurately.

• Respect cultural differences and individual patient preferences.

Key Takeaways

A comprehensive patient interview serves as the cornerstone of accurate diagnosis and high-quality patient care. Following a structured process—including the chief complaint, history of present illness, medication review, allergy assessment, medical and surgical history, family history, social history, preventive health evaluation, and review of systems—helps clinicians collect complete and reliable health information.

Using standardized frameworks such as OLD CARTS, maintaining therapeutic communication, and documenting findings accurately improves clinical reasoning, patient safety, interdisciplinary collaboration, and evidence-based decision-making.

Frequently Asked Questions

What is the purpose of a patient interview?

A patient interview gathers subjective health information, identifies the patient’s primary concerns, establishes therapeutic rapport, and provides the foundation for diagnosis, treatment planning, and clinical decision-making.

What does OLD CARTS stand for?

OLD CARTS stands for Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity. It is a structured framework used to assess the history of present illness.

Why is the chief complaint important?

The chief complaint identifies the patient’s primary reason for seeking healthcare and guides the direction of the clinical assessment, diagnostic testing, and treatment planning.

What should be included in a medication history?

A complete medication history should include:

• Prescription medications

• Over-the-counter medications

• Vitamins

• Herbal supplements

• Dietary supplements

• Medication dosage

• Route of administration

• Frequency

• Reason for use

Why is the Review of Systems (ROS) important?

The Review of Systems systematically evaluates every major body system, helping clinicians identify additional symptoms that may influence diagnosis, treatment decisions, or further diagnostic evaluation.

How should a healthcare provider conclude the interview?

Healthcare providers should summarize the information collected, answer patient questions, explain the next steps, obtain consent before the physical examination, and ensure the patient understands the plan of care.

References

Agency for Healthcare Research and Quality. (2023). Communication and patient safety. https://www.ahrq.gov/patient-safety/index.html

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. https://www.elsevier.com/books/seidels-guide-to-physical-examination/ball/978-0-323-76395-6

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/Bates%E2%80%99-Guide-to-Physical-Examination-and-History-Taking/p/9781975210878

NU566 Unit 2 The Patient Interview

Centers for Disease Control and Prevention. (2024). Adult immunization schedule by age group. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html

Jarvis, C. (2024). Physical examination and health assessment (10th ed.). Elsevier. https://www.elsevier.com/books/physical-examination-and-health-assessment/jarvis/978-0-323-82462-6