Name
Purdue University Globle
NU566 NP I – Introduction to Primary Care for the Nurse Practitioner
Prof. Name
Date
A patient interview is a systematic conversation between a healthcare provider and a patient that gathers essential health information, identifies current concerns, and supports accurate diagnosis and treatment planning. For nursing students, understanding the patient interview process is essential for developing clinical reasoning, practicing patient-centered communication, and completing comprehensive health assessments. The interview typically includes the chief complaint, history of present illness, medication and allergy history, past medical and surgical history, family and social history, preventive health information, and review of systems.
The patient interview is the first major component of a comprehensive health assessment. It allows nurses and other healthcare professionals to collect subjective data directly from the patient or, when appropriate, a caregiver or another reliable source.
During the interview, the healthcare provider explores the patient’s symptoms, medical background, lifestyle, concerns, and health goals. This information provides the foundation for the physical examination and helps guide clinical decision-making.
An effective patient interview should be organized but flexible. While a structured approach helps prevent important information from being missed, nurses should also respond to the patient’s individual needs, concerns, culture, communication style, and level of understanding.
Preparation begins before the healthcare provider asks the first question. A private, comfortable, and respectful environment encourages patients to share information openly. Reducing interruptions, maintaining appropriate privacy, and using clear communication can improve the quality of the interview.
The nurse should review available medical records, identify the purpose of the visit, and prepare any necessary assessment tools. The patient’s identity must be verified using appropriate identifiers according to organizational policy.
A professional introduction helps create trust and establishes a therapeutic relationship. The healthcare provider should explain their role and make the patient feel comfortable participating in the conversation.
Important steps include:
Introduce yourself by name and professional role.
Ask the patient how they prefer to be addressed.
Confirm the patient’s identity using appropriate identifiers.
Ask about preferred pronouns when relevant.
Explain the purpose of the interview.
Protect the patient’s privacy and confidentiality.
Use respectful, nonjudgmental language.
For example, a nurse might say:
“Hello, my name is [Name], and I am a nursing student working with your healthcare team today. I would like to ask you some questions about your health so we can better understand your concerns. Is that okay?”
Open-ended questions, active listening, and appropriate empathy help patients feel heard. The nurse should avoid interrupting unnecessarily and should allow the patient time to explain their concerns.
The Chief Complaint (CC) is the primary reason a patient seeks healthcare. It is usually documented using the patient’s own words and should briefly describe the main concern.
Examples of chief complaints include:
Chest pain
Persistent cough
Headache
Abdominal pain
Shortness of breath
Fatigue
The chief complaint is often documented as a short phrase, such as “severe headache” or “lower back pain.” Although it is brief, it guides the direction of the clinical interview and helps the healthcare provider identify which symptoms require further assessment.
Useful questions include:
“What brings you in today?”
“What is your main concern?”
“How can I help you today?”
“What symptoms are you experiencing?”
The patient should be allowed to describe the concern in their own words before the nurse begins asking more specific questions.
The History of Present Illness (HPI) is a detailed account of the patient’s current health concern. It explains how the problem began, how it has progressed, what symptoms are associated with it, and what makes it better or worse.
The HPI is especially important when assessing pain, respiratory complaints, gastrointestinal symptoms, neurological concerns, and other acute or chronic conditions.
A complete HPI commonly includes:
Symptom onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Previous treatments
Severity
One commonly used framework for organizing these details is OLD CARTS.
OLD CARTS is a clinical questioning mnemonic that helps nurses collect organized information about a patient’s symptoms. It is particularly useful when assessing pain or another chief complaint.
Onset identifies when the symptom started and whether it developed suddenly or gradually.
Ask:
“When did the symptom begin?”
“Did it start suddenly or gradually?”
“What were you doing when it started?”
“Has this happened before?”
For example, sudden chest pain that began while the patient was resting may require a different clinical response from mild discomfort that developed gradually over several weeks.
Location identifies where the symptom occurs. If the patient reports pain, determine whether it remains in one area or radiates to another location.
Ask:
“Where exactly do you feel the pain?”
“Can you point to the area?”
“Does the pain move anywhere else?”
Pain location can provide important clues about possible underlying conditions.
Duration refers to how long the symptom has been present and how long individual episodes last.
Ask:
“How long have you had this symptom?”
“How long does each episode last?”
“Is the symptom constant or does it come and go?”
“Has it become more frequent?”
The nurse should distinguish between the total time the patient has experienced a symptom and the length of each episode.
Characteristics describe the quality or nature of the symptom. Patients may use different words to explain how something feels.
For pain, descriptions may include:
Sharp
Dull
Burning
Throbbing
Aching
Cramping
Pressure-like
Ask:
“Can you describe what the pain feels like?”
Encouraging the patient to use their own words can provide more accurate information than suggesting a particular answer.
Aggravating factors are activities, situations, or conditions that make the symptom worse.
Examples include:
Physical activity
Walking
Eating
Movement
Position changes
Stress
Deep breathing
Ask:
“What makes the symptom worse?”
Identifying aggravating factors helps the provider understand symptom patterns and potential clinical causes.
Relieving factors are actions or treatments that reduce the severity of the symptom.
Ask about:
Rest
Medication
Heat or ice
Position changes
Eating or avoiding food
Relaxation
Example question:
“What have you tried that makes the symptom feel better?”
The treatment component identifies interventions the patient has already used to manage the problem.
Ask:
“Have you taken any medication for this?”
“What dose did you take?”
“When did you take it?”
“Did it provide relief?”
“Have you received treatment from another healthcare provider?”
Document the treatment and the patient’s response when known. This information helps prevent unnecessary duplication of therapy and supports safe clinical decision-making.
Severity measures how intense the symptom is. For pain, a commonly used numerical rating scale asks the patient to rate pain from 0 to 10.
A nurse may ask:
“On a scale of 0 to 10, where 0 means no pain and 10 means the worst pain imaginable, how would you rate your pain right now?”
The nurse should also consider the patient’s functional limitations, appearance, and other clinical findings. A pain score is subjective and should be interpreted alongside the overall assessment.
A medication history identifies the substances a patient currently takes or has recently taken. It is an important part of medication reconciliation and helps healthcare providers recognize potential medication-related problems.
The assessment should include:
Prescription medications
Over-the-counter medications
Vitamins
Herbal products
Dietary supplements
Medications taken only as needed
For each medication, document the name, dose, frequency, route, and reason for use when available. The nurse should also ask about adherence, recent medication changes, and any adverse effects.
Useful questions include:
“What prescription medications do you currently take?”
“Do you take any over-the-counter medications?”
“What vitamins or supplements do you use?”
“How often do you take each medication?”
“Have you recently started or stopped any medications?”
“Have you experienced any side effects?”
A medication history should include products that patients may not consider medications, such as herbal supplements and nonprescription pain relievers.
Allergy assessment is essential for patient safety. Nurses should identify allergies and document the patient’s specific reaction before administering medications or planning treatment.
Ask about:
Medication allergies
Food allergies
Environmental allergies
Latex sensitivity or allergy
The nurse should distinguish a true allergy from a side effect or intolerance whenever possible.
Important reactions to clarify include:
Rash or hives
Swelling
Difficulty breathing
Wheezing
Gastrointestinal symptoms
Anaphylaxis
Ask:
“Do you have any allergies?”
“What happens when you are exposed to that medication or substance?”
The exact reaction is important because it helps the healthcare team assess the risk associated with future exposure.
Past medical history provides information about previous diagnoses, chronic illnesses, and significant health conditions. It helps the healthcare provider understand the patient’s overall health and recognize conditions that may influence the current complaint.
Common conditions to review include:
Hypertension
Diabetes mellitus
Asthma
Heart disease
Cancer
Chronic kidney disease
Mental health conditions
Previous infections
The nurse may also assess childhood illnesses, immunization history, pregnancy history when relevant, and previous diagnostic testing.
“Have you ever been diagnosed with a chronic medical condition?”
“Do you have any ongoing health problems?”
“Have you had any major illnesses?”
“Have you had any previous diagnostic tests or procedures?”
The information collected should be relevant to the patient’s current health needs and documented accurately.
Past surgical history identifies previous operations, procedures, and hospital admissions. These details may affect current treatment decisions, medication planning, and assessment findings.
Document, when available:
Type of surgery or procedure
Date of surgery
Reason for the procedure
Hospitalizations
Reason for admission
Complications
Recovery history
Ask:
“Have you ever had surgery?”
“Have you ever been hospitalized?”
“Did you experience any complications?”
Previous surgeries may affect anatomy, mobility, pain, or the risk of complications. Hospitalization history can also reveal serious illnesses or recurring health problems.
Family history helps identify inherited conditions, familial disease patterns, and health risks. The nurse should ask about significant illnesses affecting close relatives, including parents, siblings, and children when relevant.
Conditions commonly explored include:
Heart disease
Hypertension
Diabetes
Stroke
Cancer
Mental health disorders
Autoimmune diseases
Genetic disorders
“Do any close family members have significant health conditions?”
“Have any family members been diagnosed with heart disease or cancer?”
“Are your parents and siblings living and healthy?”
“Is there a history of inherited illness in your family?”
The nurse should document the condition, affected family member, and age of onset when known. This information can help identify patients who may benefit from additional screening or genetic counseling.
Social history assesses lifestyle, living conditions, relationships, and behaviors that may influence health. It is an important part of patient-centered care because social factors can affect access to treatment, disease risk, and the patient’s ability to follow a care plan.
Areas commonly assessed include:
Occupation and education
Living arrangements
Relationship status
Tobacco use
Alcohol consumption
Recreational drug use
Sexual history
Exercise habits
Diet and nutrition
Home safety
Exposure to violence
Social support
Ask questions in a respectful and nonjudgmental manner.
Examples include:
“Do you currently smoke or use tobacco products?”
“How often do you drink alcohol?”
“Do you use recreational drugs?”
“Have you tried to quit smoking before?”
If the patient uses tobacco, assess the type of product, duration of use, amount used, and previous quit attempts. These details can support health education and smoking cessation planning.
The nurse should assess whether the patient feels safe at home and has access to necessary support.
Questions may include:
“Who do you live with?”
“Do you feel safe at home?”
“Do you have someone who can help you if needed?”
“Are there any concerns about food, housing, or transportation?”
Sensitive topics should be discussed privately whenever possible. The provider should follow appropriate safeguarding and reporting requirements if safety concerns are identified.
Preventive health history determines whether the patient is receiving appropriate health screenings, vaccinations, and health education. Recommendations depend on age, sex, medical history, risk factors, and current clinical guidelines.
Common preventive health topics include:
Immunization status
Cervical cancer screening
Breast cancer screening
Colorectal cancer screening
Prostate cancer screening when appropriate
Bone health and osteoporosis screening
Blood pressure assessment
Diabetes screening
Tobacco and alcohol counseling
The nurse should avoid assuming that every patient requires the same screening tests. Preventive care should be individualized according to current recommendations and the patient’s risk profile.
“Are your vaccinations up to date?”
“When was your last cervical cancer screening?”
“When was your last colorectal cancer screening?”
“Have you had a recent blood pressure or diabetes screening?”
“Have you discussed age-appropriate cancer screening with your healthcare provider?”
Breast and testicular health should be addressed using current evidence-based recommendations and individualized clinical guidance.
The Review of Systems (ROS) is a systematic assessment of symptoms affecting the body’s major systems. It is generally performed after the history of present illness and other relevant health history have been explored.
The ROS helps identify additional symptoms that the patient may not have mentioned when describing the chief complaint. It is not the same as the physical examination. The ROS gathers subjective information through questions, while the physical examination collects objective findings through observation, palpation, auscultation, and other techniques.
The following categories provide a practical head-to-toe review.
Assess the patient’s overall health status and energy level.
Ask about:
Fever
Chills
Fatigue
Unintentional weight loss or gain
Night sweats
Changes in appetite
Changes in energy
Assess for changes in skin appearance and integrity.
Ask about:
Rashes
Bruising
Skin discoloration
Changes in moles
Delayed wound healing
Itching
New or changing skin lesions
Review visual symptoms and eye health.
Ask about:
Blurred vision
Vision loss
Eye pain
Redness
Corrective lens use
Changes in visual acuity
Assess hearing and ear-related symptoms.
Ask about:
Hearing loss
Ear pain
Ringing in the ears
Ear discharge
Dizziness associated with ear symptoms
Review symptoms affecting the upper respiratory and oral systems.
Ask about:
Nasal congestion
Nosebleeds
Sore throat
Hoarseness
Difficulty swallowing
Dental problems
Mouth sores
Assess breast-related symptoms when clinically appropriate.
Ask about:
Breast lumps
Breast pain
Skin changes
Nipple discharge
Other new breast concerns
Breast health questions should be approached sensitively and based on the patient’s symptoms, history, and screening needs.
These systems are assessed for symptoms associated with blood disorders, lymphatic conditions, and hormonal problems.
Ask about:
Easy bruising
Abnormal bleeding
Swollen lymph nodes
Previous blood transfusions
Excessive thirst
Increased urination
Heat or cold intolerance
Changes in appetite
Assess symptoms that may indicate cardiovascular disease.
Ask about:
Chest pain or pressure
Palpitations
Shortness of breath with activity
Leg swelling
Orthopnea
Paroxysmal nocturnal dyspnea
History of heart disease
Orthopnea refers to difficulty breathing when lying flat. Paroxysmal nocturnal dyspnea refers to episodes of shortness of breath that awaken a person from sleep.
Review symptoms affecting breathing and lung health.
Ask about:
Cough
Wheezing
Shortness of breath
Hemoptysis
Previous pneumonia
Tuberculosis exposure or history
Asthma or other respiratory conditions
Hemoptysis means coughing up blood. Any concerning respiratory symptom should be assessed further based on severity and clinical context.
Assess digestive symptoms and bowel habits.
Ask about:
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Heartburn
Difficulty swallowing
Black or bloody stools
History of ulcers
Hepatitis or liver disease
Changes in bowel habits, gastrointestinal bleeding, and persistent abdominal symptoms may require additional assessment.
Review urinary, reproductive, and sexual health concerns using respectful, inclusive communication.
Ask about:
Urinary frequency
Urgency
Pain or burning with urination
Blood in the urine
Sexual health concerns
Sexually transmitted infections
Contraceptive use
Reproductive health history
For patients with relevant gynecologic history, ask about:
Last menstrual period
Menstrual patterns
Pregnancy history
Vaginal discharge
Pelvic pain
Cervical cancer screening history
For patients with relevant prostate or testicular health concerns, assess:
Urinary symptoms
Prostate concerns
Testicular changes
Previous prostate evaluation
Screening recommendations should be individualized rather than based only on sex or gender.
Assess movement, strength, and musculoskeletal symptoms.
Ask about:
Joint pain
Joint swelling
Muscle weakness
Back pain
Fractures
Difficulty walking
Osteoporosis history
Reduced range of motion
These questions help identify problems that may affect mobility, independence, and daily activities.
Review symptoms involving the nervous system.
Ask about:
Headaches
Dizziness
Weakness
Numbness
Tingling
Seizures
Fainting
Paralysis
Changes in balance or coordination
Neurological symptoms should be explored in detail, especially when they are new, sudden, or associated with other concerning findings.
Mental health assessment is an important part of the patient interview. The nurse should ask about mood, emotional well-being, sleep, and safety in a supportive and nonjudgmental manner.
Assess for:
Depression
Anxiety
Sleep disturbances
Mood changes
Previous psychiatric diagnoses
Suicidal thoughts
Previous mental health treatment
When suicidal thoughts or immediate safety concerns are identified, the nurse should follow the appropriate emergency assessment and institutional safety procedures.
After completing the health history, the nurse should summarize the information and explain the next step. The patient should understand what will happen before the physical examination begins.
A professional transition may sound like:
“Thank you for answering my questions. I have gathered information about your health concerns. Next, I would like to perform a physical examination to collect additional information. I will explain each step as we go. Do you have any questions before we begin?”
The provider should obtain appropriate consent, explain procedures, respect privacy, and offer the patient an opportunity to ask questions.
The patient interview is a fundamental nursing skill that supports accurate assessment, therapeutic communication, and safe clinical care. A structured interview helps nurses collect subjective data while recognizing the patient’s concerns, preferences, and individual health needs.
The most important components to remember are:
Chief Complaint: Identifies the patient’s primary reason for seeking care.
HPI: Explores the current symptom using a framework such as OLD CARTS.
Medication and Allergy History: Supports medication safety and treatment planning.
Past Medical and Surgical History: Identifies previous conditions, procedures, and hospitalizations.
Family History: Helps identify inherited conditions and familial risk factors.
Social History: Assesses lifestyle, living conditions, substance use, and safety.
Preventive Health History: Reviews screenings, immunizations, and health promotion.
Review of Systems: Screens for symptoms across major body systems.
Transition to Physical Examination: Explains the next step and supports patient consent.
An effective patient interview is not simply a list of questions. It is a professional, patient-centered conversation that combines active listening, clinical reasoning, accurate documentation, and respect for the patient’s dignity.
The purpose of a patient interview is to collect subjective health information, identify the patient’s main concerns, build rapport, and support diagnosis, treatment planning, and clinical decision-making. It is the foundation of a comprehensive health assessment.
OLD CARTS is a symptom assessment mnemonic used during the history of present illness. It stands for Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
The chief complaint identifies the patient’s primary reason for seeking healthcare. It guides the interview, helps prioritize assessment, and directs the provider toward the symptoms requiring further investigation.
A medication history should include prescription medications, over-the-counter drugs, vitamins, herbal products, and dietary supplements. The nurse should document medication names, doses, frequency, route, reason for use, and relevant adverse effects or adherence concerns.
Allergy assessment helps prevent medication-related harm and other allergic reactions. Nurses should identify the substance involved and clarify the patient’s specific reaction before treatment.
The HPI provides detailed information about the patient’s current chief complaint, including onset, location, duration, and severity. The ROS is a systematic screening of symptoms across the major body systems to identify additional concerns.
The nurse should summarize the information gathered, clarify any unanswered questions, explain the next step, and obtain appropriate consent before beginning the physical examination.
Agency for Healthcare Research and Quality. (n.d.). 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-Guide-to-Physical-Examination-and-History-Taking/p/9781975210878
Centers for Disease Control and Prevention. (2024). Adult immunization schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.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
