Challenges exist in directing students to collect a condensed, current, and pertinent health history in a timely manner that accompanies a focused bedside examination. Today's nursing students are overwhelmed with gathering and synthesizing a comprehensive health history as they sift through a plethora of information hidden in electronic medical records (EMR). It is estimated that 70% to 90% of a diagnosis can be made by eliciting a precise patient history (Muhrer, 2014). When done well, an abbreviated history can help students achieve a new level of critical thinking.
Students were introduced to two mnemonics—OLDCART and NEWS-C—during their first medical surgical rotation to mitigate a noted weakness in history taking. Faculty observed that students spent the majority of their time reviewing the EMR and then approached patients for a focused physical examination. The implementation of this mnemonic duo directed students to “find OLDCART” and “get the NEWS-C” for every patient encounter in the classroom and clinical setting.
The goal of this exercise was to help students collect a timely, patient-centered, focused bedside history to accompany the physical examination. Objectives were for students to synthesize the data from a bedside history and physical examination, formulate an applicable nursing diagnosis, and create a precise plan of care.
OLDCART is a symptom assessment mnemonic model to help health care providers ask appropriate questions when exploring patients' symptoms (Tagney & Younker, 2012). The elements of OLDCART include:
- Onset of complaint: When did the symptoms start?
- Location of symptoms: Where do the symptoms occur?
- Duration of symptoms: How long do the symptoms occur or last? Over time, do the symptoms worsen, improve, or remain stable?
- Characteristics of the symptoms: Using a 10-point scale, how do the symptoms feel or look, and what is their intensity?
- Aggravating factors: What makes the symptoms worse? What triggers the symptoms?
- Relieving factors: What makes the symptoms better?
- Treatment tried: What treatments have you tried? What are the results of treatments? (Henrich, 2017).
NEWS-C is a modified and shortened version of Gordon's (2013) 11 functional health patterns. It queries the effect of patients' current symptoms vis-à-vis their function. For this assignment, students focused on “getting the NEWS.” The elements of NEWS-C describe, “What effects do symptoms have on . . .”:
- Nutrition (eating, drinking, or appetite): What have you eaten or had to drink in the past 24 hours?
- Elimination (bowel and bladder habits): What affect do the symptoms have on your urination or bowel habits?
- Work and activity (work, exercise, activity, and leisure): What affect do the symptoms have on your activities of daily living or at work?
- Sleep (sleep, rest, and relaxation): What affect do the symptoms have on your sleep and rest?
- Coping (handling stress and effective coping patterns): How do you cope with these symptoms? (Gordon, 2013).
After seeing the improvement in diagnostic reasoning when students used these mnemonics, a brief student questionnaire was designed, implemented, and evaluated. Evaluation of this project found that 100% (n = 37) of the students used OLD-CART and 66% (n = 25) used NEWS-C in the clinical setting when planning care for their patients. Students stated the mnemonics were “helpful,” “gave new insights for what was going on with the patient,” and were “an easy way to remember important assessments.” Faculty noticed this approach directed students to focus on key assessments in formulating an individualized plan of care. Clinical faculty were introduced to this new assessment approach through student presentations during grand rounds.
As the semester progressed, student and faculty learning were reinforced through demonstration and practice. Combining OLDCART and NEWS-C created a succinct, thorough, and manageable patient-centered history, and faculty found these mnemonics also augmented the focused bedside examination. Future implementation will include the application of these mnemonics in subsequent paired didactic and clinical courses across the curriculum.
Patient history changes daily. An innovative focused history collection using question-specific mnemonics (OLDCART and NEWS-C) allowed students to focus on key points when entering a patient's room, begin a conversation with the patient, and set goals for creating a plan of care. Faculty can use this approach to rethink health assessment strategies as a means to direct patient care and enhance critical thinking of students. This innovative approach to collecting a patient-centered history is unique and applicable to multiple patient situations.
Brenda A. Senger, PhD, RN
Deborah W. Smith, DNP, ARNP, FNP-BC
- Gordon, M. (2013). Functional health patterns. Retrieved from http://currentnursing.com/theory/functional_health_patterns.html
- Henrich, C. (2017). Musculoskeletal system, Cleveland Clinic. PowerPoint slide 2. Retrieved from http://www.clevelandclinicmeded.com/live/owork/US-State-2017/presentations-nurse/02%20at%201245%20Henrich%20Ortho%20MS%20and%20Pain%20v2.pdf
- Muhrer, J. (2014). The importance of the history and physical in diagnosis. Nurse Practitioner, 39(4), 30–35.
- Tagney, J. & Younker, J. (2012). Clinical skills: History taking in cardiac patients. British Journal of Cardiac Nursing, 7(12), 588–594.