The first and often most important interaction a nurse has with a patient is their initial nurse intake interview, also called a health assessment. This is when you meet the patient and gather information about symptoms and health history. A standard health assessment will give you and other healthcare providers the necessary baseline to start further evaluation and eventual treatment.
Performing a patient health assessment can become rote. To a certain degree, this is a good thing—for a highly competent nurse this exercise is second nature. But this doesn’t mean they should all be the same, and for inquisitive nurses looking to make an intake even smoother and more efficient, there are ways to take your nurse-patient interview from standard to a higher standard.
Ready to become an even better nurse? Learn strategies and habits that can make a difference in patient outcomes. Here are some intake basics and health assessment best practices, as well as tips to overcome certain intake obstacles.
Nurse-Patient Health Assessment Basics
Let’s start with what they do teach you in nursing school before we move on to some pro tips and troubleshooting techniques you might find useful on a case-by-case basis. So what is a standard intake process a nurse performs? First consider the purpose of an intake assessment—information gathering. If you think gathering patient history is just a routine step in patient intake, consider that patient history provides 70% of diagnoses. It’s routine because it’s important.
During your initial patient assessment, you’ll want to collect the following information:
- Data (objective and subjective)
- Family history
- Medical and surgical history
- Medication history
- Psychosocial history
In many healthcare settings, a patient will fill out a standardized form that includes much of the above, either in the waiting room or in advance of their appointment. During your intake interview, you may also want to obtain information about the patient’s sociological and spiritual needs.
In addition to collecting the health history of the patient, you’ll do the initial physical assessment to gather some immediate information about the patient’s condition. This physical part of the intake assessment involves checking vital signs and other physical statuses that will often include:
- Blood pressure
- Temperature
- Heart rate
- Respiratory rate
- Weight
- Pain scale
Both patient history and physical data collection give you and other providers treating the patient a baseline to begin making decisions about what’s next, whether that includes collecting additional data through further examination or tests, or moving forward with a care plan and treatment schedule. The complexity of the patient’s condition will often guide how much additional assessment is needed.
Creating the Nurse-Patient Relationship
Creating and cultivating a nurse-patient relationship is one of the soft skills of nursing that can have a significant impact in setting treatment up for success. Since the patient’s intake interview is likely your first interaction, this is your opportunity to create a foundation for communication and trust.
For a detailed look at this first interaction, we invite you to view our post on How to Make a Good First Impression on a Patient[1] , but here are some practical ways to make this part of the process count by treating this face-to-face as an opportunity to establish the right rapport:
- Make Eye Contact: Meeting your patient’s eyes demonstrates that they have your full attention, and are there to make a connection.
- Offer a Smile: Your patient needs a friendly face, particularly if they are concerned about their symptoms.
- Speak Clearly and Politely: Always be professional with your patient, but that doesn’t mean you have to be impersonal. Use language they can follow, and keep it warm.
- Practice Active Listening: Prepare to listen, don’t interrupt, observe physical cues, and be responsive. Sometimes patients communicate with more than words.
- Respect Personal Space: Until or unless you start a physical exam, give your patient at least an arm’s length. There’s science behind this, and it’s called proxemics.
If you follow these rules of thumb and other intuitive courtesies to put your patient at ease, they may feel more comfortable with you, and therefore more forthcoming about any symptoms or histories they might otherwise omit. The more you know, the better everyone’s chance at a good patient outcome. Your patient might not have any questions (yet) but if they do, make room for them. Show your patient you’re there to provide them with information, too.
Strategies for Effective and Empathetic Communication
Empathy is a broad term, but you’ll need it to conduct a superior intake interview when recording a patient’s history and symptoms. In addition to active listening (mentioned above), there are techniques you can use to put your patient at ease and foster trust:
Nonverbal Communication: In addition to observing your patient for nonverbal behavior that can give you clues about your patient’s pain or anxiety, you can communicate non-verbally as well. Here are a few ways to communicate while saying nothing:
- Stillness: While your patient is speaking, adopt a relaxed posture and try not to fidget. Stillness communicates to your patient that you are listening attentively. You can even mirror your patient’s position to show empathy.
- Physical Contact: Follow your patient’s nonverbal lead on whether to offer a reassuring touch. Some patients may not want physical contact, but for others holding their hand or placing yours on their arm or back can make them feel less alone.
- Eye Contact: Again, meeting your patient’s eyes is a good way to connect. Your patient is operating from a place of uncertainty, and eye contact may reassure them that you’re not avoiding anything difficult or embarrassing.
- Silence: Sometimes a moment of silence will give the conversation the space it needs to continue. Don’t interrupt your patient; they might have more to say about a symptom or history.
A Shared Experience: Remember that you and your patient are in this together. Sharing a laugh, some hope, or even a little something about yourself can help humanize your interaction, and create a stronger sense of connection.
- Share Humor: Sharing an appropriate laugh with a patient can help ease tension and foster connection. You may be able to find humor in a shared culture, if you have one.
- Share Hope and Positivity: Even if your patient is facing a difficult prognosis or course of treatment, try to instill hopefulness and the possibility of a positive outcome.
- Share Yourself: Within appropriate nurse-patient boundaries, disclosing a little bit about yourself promotes togetherness, shared trust, and may help your patient feel less alone.
Read (and Ask) Between the Lines: As a nurse, you’re not just there to receive information, but to focus the conversation and interpret where more clarity or disclosure might help. Use communication tactics that can help you make the most of your intake conversation:
- Maintain Focus: Don’t let the conversation get lost in irrelevant anecdotes or banter. Gently steer things back to the issues at hand when you need to.
- Pursue Clarifications: Ask your patient to elaborate or reframe anything that feels unclear or could be interpreted in more than one way. Having your patient rephrase something you’re not sure about will help you avoid miscommunication.
- Summarize and Reiterate: Summarizing the patient’s own information back to them may lead them to clarify or correct something important. Keep your summary clear and in terms everyone can follow.
- Invite Questions: Don’t end your intake without opening up for questions, if appropriate. Not only does this empower and inform your patient, you never know when a patient’s question will actually reveal something that did not come out naturally before.
What to Do When a Patient Isn’t Cooperative
Not every patient assessment will go smoothly, no matter how prepared and adaptive you are. A patient may be uncooperative or unforthcoming for many reasons that aren’t necessarily deceitful. They may be embarrassed, fearful, forgetful, or may simply not understand what kind of information is important to share. Many patients may not know their full family health histories, or even their own health history in entirety.
Any scenario where a patient leaves out key information is compromising their safety. Often this omission is unintentional; for example, a patient may not mention a symptom they see as irrelevant or innocuous, but may in fact lead to a diagnosis. There’s no way to know what a patient is leaving out, but if symptoms suggest there’s more to the story, the best thing you can do is ask questions and encourage your patient to share even those details they might deem unrelated.
Another possible scenario is a patient who is lying out of guilt or embarrassment. You may pick up on this through body language, like a delayed response to a question or avoiding eye contact. Perhaps your patient hasn’t been taking their medication on schedule because their financial situation has changed and they can’t afford it. Maybe you suspect your patient is embellishing their exercise regime and attention to nutrition, or downplaying smoking habits. In these instances, the nurse-patient relationship is your friend. You can express gentle skepticism to prod out the truth, or offer advice that takes a likely omission into account.
Yet another possibility is that you have a patient with a substance abuse disorder who lies about their substance use either out of shame or, worse, in the interest of obtaining a prescription. Your facility may have specific policies in place for these scenarios, such as asking patients to sign an agreement that they won’t seek another prescription for a controlled substance elsewhere. That conversation will likely take place with the doctor, but your communication skills and instincts can be lifesaving when it comes to avoiding prescription interactions or worse.
Scenarios involving patients with behavioral issues that may need a very specific type of approach that warrants their own discussion and set of protocols. Make sure you’re familiar with your organization’s protocols, safety measures and other resources for interacting with these types of patients.
Hopefully in most instances, however, you’ll be able to tease out the information you need using the techniques above, if the patient doesn’t offer it without some questioning. If not, it may become necessary to confront the patient about falsehoods to correct the assessment. If it comes to that, stay nonjudgmental and remind your patient that you truly need all the information—especially the uncomfortable information—to keep them safe.
Concluding Your Assessment
Once you’ve concluded your intake interview with the patient, allowed for questions, asked for clarification, and pursued any missing information, end the assessment with courtesy and warmth. Remember to thank your patient by name and, if you’ll be seeing them again, remind them of yours. You’ve completed your first collaboration in the health of your patient, setting them up for a good experience and the best possible outcome.
WCU provides career guidance and assistance but cannot guarantee employment. The views and opinions expressed are those of the individuals and do not necessarily reflect the beliefs or position of the school or of any instructor or student.
