Good decisions depend on good information. A professional combines what the patient says, what is observed, what is measured, what is documented and what colleagues or family report. The source, reliability, timing and confidentiality of every piece of information must be considered.
Add an image showing patient interview, observation, records and team handover here.
Learning outcomes
- Define primary, secondary, subjective and objective sources of information.
- Collect a complete history using interview, observation, examination, records and handover.
- Check reliability, relevance, accuracy, currency and completeness.
- Use structured communication while protecting consent, confidentiality and data security.
- Document findings so another professional can understand and act safely.
1. Primary and secondary sources
| Source | Meaning | Examples |
|---|---|---|
| Primary source | Information obtained directly from the patient or direct measurement. | Patient’s pain description, observed gait, respiratory rate, pulse, wound measurement or functional test. |
| Secondary source | Information obtained from another person or existing record. | Relative, caregiver, ambulance crew, referral letter, medication list, imaging report or previous notes. |
| Subjective information | What the patient or informant reports and feels. | “My shoulder pain is 7/10 when I reach overhead.” |
| Objective information | What can be observed, measured or verified. | Limited abduction, swelling, pulse 110/min or temperature 38.2°C. |
2. Main sources used in clinical care
- Patient interview: symptoms, concerns, goals, history, medications, allergies, function, lifestyle and consent.
- Observation: appearance, behaviour, posture, breathing, mobility, skin colour, speech, distress and environmental risks.
- Physical examination: inspection, palpation, range of movement, strength, sensation, reflexes, vital signs and functional tasks within scope.
- Family or caregiver: baseline function, onset of confusion, medication adherence, home environment and safeguarding information.
- Patient-held records: appointment cards, medication packets, previous results, immunisation records and discharge instructions.
- Clinical records: nursing notes, physiotherapy assessment, doctor’s notes, operative reports, imaging, laboratory results, fluid charts and observation charts.
- Handover and referral: information from ambulance crews, emergency departments, wards, community workers and multidisciplinary colleagues.
- Technology: electronic medical records, pulse oximetry, monitors, digital photographs authorised by policy and telehealth reports.
- Research and guidelines: evidence-based protocols, standard operating procedures, national guidelines and professional standards.
3. Interview techniques
- Prepare a private, quiet environment and introduce yourself.
- Confirm identity and explain why information is being collected.
- Start with an open question: “What brought you here today?”
- Allow the patient to speak before narrowing the history with focused questions.
- Clarify onset, site, character, severity, timing, aggravating/relieving factors and associated symptoms.
- Use plain language, avoid leading questions and check understanding with teach-back.
- Summarise back to the patient and invite correction.
- Record the patient’s own important words in quotation marks rather than replacing them with assumptions.
4. Observation and examination
| Approach | What to collect | Safety requirement |
|---|---|---|
| General survey | Appearance, distress, consciousness, posture, hygiene, speech and mobility | Maintain dignity; expose only as much as necessary. |
| Vital signs | Pulse, respirations, blood pressure, temperature, SpO₂ and pain | Use calibrated equipment and document time, position and site. |
| Focused physical examination | Relevant skin, wound, joint, neurological, respiratory or cardiovascular findings | Consent, explain touch, compare sides where safe and stop if severe pain or deterioration occurs. |
| Functional assessment | Transfers, gait, reach, grip, self-care and participation | Use guarding, mobility aids and falls precautions. |
5. Reliability and verification
Information is not automatically true because it is written down or repeated. Check whether it is consistent with the patient’s appearance and measurements, whether it is current, and whether the source had an opportunity to observe the event.
- Accuracy: repeat an unexpected observation and check equipment technique.
- Currency: distinguish a past diagnosis from a current problem and record the time of each observation.
- Completeness: do not omit allergies, medicines, anticoagulants, pregnancy, mechanism of injury or baseline function.
- Consistency: clarify discrepancies respectfully—for example, a reported fall time that differs between witnesses.
- Bias: avoid assumptions based on age, disability, appearance, language, occupation or diagnosis.
- Escalation: immediately report new red flags rather than waiting to finish routine documentation.
6. Structured handover: ISBAR
| Element | What to say |
|---|---|
| Identify | Your name, role, location and patient identifiers. |
| Situation | The immediate problem and why help is needed now. |
| Background | Relevant diagnosis, mechanism, history, medicines, allergies and baseline function. |
| Assessment | Vital signs, examination findings, pain, response to treatment and concerns. |
| Recommendation | What you need the receiving professional to do and how urgently. |
7. Confidentiality and information security
- Collect only information necessary for care and explain how it will be used.
- Share information with the care team on a need-to-know basis and follow consent and legal requirements.
- Keep paper records secure; lock screens and use approved systems for electronic records.
- Never discuss identifiable patients in public places or post clinical photographs on social media without authorised consent and policy compliance.
- Document factual observations, not insults, speculation or judgemental labels.
8. Scenario
Scenario: A patient arrives after a fall and says, “I am fine,” but is pale, confused and unable to bear weight. Good practice: do not rely on the brief statement alone. Perform a rapid safety and ABCDE screen, obtain vital signs, ask witnesses about the mechanism, inspect for bleeding or deformity, check medicines/anticoagulants, document the time and escalate the discrepancy urgently.
Exam points and revision questions
- Differentiate primary, secondary, subjective and objective information.
- List eight sources of information used in clinical practice.
- Explain how you would verify an unexpected vital-sign result.
- Write an ISBAR handover for a deteriorating patient.
- Describe five ways to protect confidentiality.