Health History and Therapeutic Interview Techniques

The health history and patient interview are the foundation of every nursing assessment. This note reviews how to collect a complete health history, distinguish subjective from objective data, conduct each phase of the interview, use therapeutic communication, and analyze symptoms with OLDCARTS — all common NCLEX testing areas.

Definitions

• Health history: the systematic collection of subjective data about a patient's current and past health status; the first step in the nursing assessment process.
• Interview: a therapeutic communication process used to gather health information while establishing trust and rapport.

Components of a Complete Health History

• Biographical data — name, age, gender, date of birth, occupation, marital status, living situation, religion, language, insurance status.
  • Example: A 72-year-old male.
• Chief complaint (CC) — the main reason the patient seeks care, in the patient's own words.
  • Example: "I have chest pain that started two hours ago."
• History of present illness (HPI) — detailed analysis of the current problem using OLDCARTS.
  • Example: Pain began yesterday, substernal, lasts 5–10 minutes, sharp in character.
• Past medical history (PMH) — previous diagnoses, surgeries, hospitalizations, injuries, allergies, medications.
  • Example: Hypertension, appendectomy in 2015, daily lisinopril.
• Family history — health conditions in blood relatives such as parents and siblings.
  • Example: Father had an MI at age 60; mother has diabetes.
• Social history — smoking, alcohol, drugs, occupation, diet, sleep, exercise, support systems.
  • Example: Smokes one pack/day for 40 years; retired truck driver.
• Review of systems (ROS) — systematic head-to-toe inquiry of each body system.
  • Example: Patient denies shortness of breath, cough, or leg swelling.

Types of Health History Data

• Subjective data — what the patient reports.
  • Example: "I feel short of breath when I walk upstairs."
• Objective data — what the nurse observes or measures.
  • Example: Oxygen saturation 89%; crackles in the lungs.
• Primary data — obtained directly from the patient.
• Secondary data — obtained from family, caregivers, or medical records.

NCLEX focus

• Subjective data is collected during the interview; objective data is collected during the physical assessment.
• If the patient cannot communicate, identify the most appropriate secondary source (caregiver, family, records).

Phases of the Interview

Pre-interview phase

• Review available records, ensure privacy, and prepare materials.

Introduction phase

• Introduce yourself by name and role; explain the purpose and expected duration of the interview.

Working phase

• Begin with open-ended questions to encourage detailed responses.
• Use focused (closed-ended) questions to clarify information.

Closing phase

• Summarize the information collected and verify accuracy.
• Ask whether the patient has additional concerns.

NCLEX focus

• Use open-ended questions at the beginning of data collection to avoid limiting responses.
• Summarization at the end is required to confirm accuracy and completeness.

Therapeutic Communication Techniques

• Active listening — full attention, no interrupting, appropriate eye contact.
• Open-ended questions — invite detailed responses.
• Restating — repeating the patient's statement to confirm understanding.
• Clarifying — asking the patient to explain unclear statements.
• Summarizing — reviewing key points to ensure accuracy.

Non-Therapeutic Communication to Avoid

• "Why" questions — make patients feel defensive.
• Leading questions — suggest a desired answer and bias responses.
• False reassurance — dismisses concerns and reduces trust.
• Medical jargon — confuses patients; use simple language.

NCLEX focus

• The most therapeutic responses are open-ended, patient-centered, and non-judgmental.
• Communication that interrupts, judges, or redirects away from the patient is incorrect.

OLDCARTS for Symptom Analysis

• O – Onset: When did the symptom begin?
• L – Location: Where is it felt?
• D – Duration: How long does it last?
• C – Character: What does it feel like (sharp, dull, etc.)?
• A – Aggravating factors: What worsens it?
• R – Relieving factors: What improves it?
• T – Timing: When does it occur?
• S – Severity: Intensity, often 0–10.

NCLEX focus

• OLDCARTS applies to any symptom — pain, nausea, shortness of breath, etc.
• Pain is always subjective and must be self-reported by the patient.

Cultural and Developmental Considerations

• Use a professional (certified) interpreter when there is a language barrier.
• Family members or children should never serve as medical interpreters.
• Adjust interview techniques to the patient's developmental stage and communication ability.

NCLEX focus

• Do not assume cultural beliefs — ask respectful, open-ended questions.
• Only certified interpreters are acceptable for informed consent and clinical communication.

Special Interview Situations

• Agitated patient: speak calmly, maintain safety, avoid confrontation.
• Overly talkative patient: redirect with focused questions; set time boundaries.
• Silent patient: use silence, observe non-verbal cues, offer simple prompts.
• Crying patient: allow silence, offer tissues, validate emotions.

Common Exam Traps

• Confusing subjective with objective data.
• Using closed-ended questions at the start of the interview.
• Using family members as interpreters.
• Asking "why" questions (judgmental).
• Offering false reassurance.

Key takeaways

• The health history includes biographical data, CC, HPI, PMH, family history, social history, and ROS.
• Subjective data comes from the patient; objective data comes from observation or measurement.
• Open the interview with open-ended questions and close it with a summary for accuracy.
• Use OLDCARTS to analyze any symptom in a structured way.
• Use only certified professional interpreters when language barriers exist — never family or children.
• Pain is always subjective and must be self-reported.