History taking is a key component of a nursing patient assessment and an important part of prioritizing and planning care. Traditionally, a medical history is undertaken for a diagnosis and to ultimately decide on appropriate treatment. A nursing history should be carried out jointly and is regarded as a key skill that develops through experience. It should include physical, social and psycho-emotional domains. In its simplest form, history taking involves asking appropriate questions to children, young people and/or their families to obtain vital information to assist the subsequent care. An overview of history taking and its components can be seen in the Figure.

• The aims of history taking can be summarized as:
  
• to find out more about presenting symptoms and identify problems that may not be immediately obvious;
  
• to direct necessary examination and further investigations;
  
• to reach a definite or differential diagnosis;
  
• to establish a rapport and a therapeutic relationship with the child and parents;
  
• to tailor appropriate treatment strategies.

Nursing history taking fits well with a person-centred approach to care where nurses are expected to get to know their patients and understand the needs and problems of the children in their care. Integral to this process is the need for effective communication skills, which should aim to achieve holistic, thorough history taking in the context of a therapeutic relationship.

An essential part of person-centred communication during history taking is the establishment of rapport between the nurse and child or young person and family. See the Figure for the Calgary-Cambridge communication framework that can be used to understand the vital elements of this process. This covers elements that are required for any patient but they can easily be applied to a child, young person and their parents.

Other factors need to be considered in relation to communication during history taking. If a child or family does not speak English, it will be necessary to arrange an interpreter to clarify what is said. In addition, for very young children or those who have no or limited speech, the history is taken from the parents. In older children, there must be a balance between giving them independence and getting a full account of the illness or situation.

Communication during history taking may also be compromised by factors such as the child’s distress. Parents may be extremely anxious, particularly in settings such as accident and emergency rooms. Histories may therefore need to be brief and focused. If a comprehensive history is not achievable in the first instance, it may be necessary to continue adding detail later. The nature of nursing means that relationships between nurses and children or young people in their care can be developed over a longer period, with more frequent contact than other members of the multi-disciplinary team. Within this context, history taking can be seen as a process of getting to know the child and family better and to understand their needs and concerns. It can also be viewed as an incremental process where information is accumulated over time. This means history taking need not necessarily take place in a formal consultation and can take place informally, depending on the situation. Whatever mode is employed, there are key components of any history taking, discussed below.

In the hospital setting, history taking can follow a structured approach using, for example, a mnemonic to aid comprehensive information gathering. One example of such a framework is the mnemonic SAMPLE.

• S = symptoms in relation to the current concern or presenting complaint. For example; when and how did the symptoms start? Was the child well before? Have there been similar episodes or similar illnesses in the family or school?
  
• A = allergies and whether the child has any existing reaction to a known substance.
  
• M = medication. Is the child currently taking any prescribed drugs? In addition, if recreational drug use is a possibility, this can also be considered here.
  
• P = past medical history of the child which is a key element in history taking. This can look back as far as pregnancy. For example, in babies, were any factors relevant to foetal development and well-being important such as antenatal infection, blood group incompatibility, maternal illness? What was the gestation and birth weight? Were there any birth injuries or the need for resuscitation? In children, have there been any previous illnesses or are there any systems that require particular attention. A developmental approach can also be considered as well as the social, mental and family history.
  
• L = when did the child last eat and drink?
  
• E = whether there were any events that led to the current situation, for example, accidents?

Finally, it is essential that a compassionate approach be upheld in history taking which demonstrates attention to privacy and dignity as well as upholding confidentiality. This may not be easy in a busy environment where space is limited. This highlights the potential ethico-legal implications in relation to how information is collected and protected. Additionally, issues of safeguarding are also important to take account of recognizing that not all parents or carers have the child’s best interests at heart and may conceal vital facts, hindering a full and accurate picture. Multi-disciplinary support in such cases may be sought.