Communication is vital to assessment. It is important to build a good rapport with the patient. The initial assessment interview not only allows the nurse to obtain baseline information about the patient but also facilitates the establishment of a therapeutic relationship (Crumbie [18]). It is vital that the nurse demonstrates interest and respect to the patient from the very start of the interview. Some of the information requested is likely to be of a searching and intimate nature, which may be difficult for the patient to disclose. The nurse should emphasize the confidential nature of the discussion and take steps to reduce anxiety and ensure privacy; the patient may modify their words and behaviour depending on the environment. Taking steps to establish trust and develop the relationship early on will set the scene for effective and accurate information exchange (Silverman et al. [79]).

Interviewing is a skill and an art; it should be both patient centred and clinician centred. The clinician seeks to elicit the full story of the patient's symptoms but must also collect key information in order to complete the assessment and develop a plan. Allowing patients to lead the interview process allows clinicians to understand patients’ thoughts, ideas and concerns without adding their own perspective (see Chapter c05: Communication, psychological wellbeing and safeguarding).

In contrast, a clinician‐centred or symptom‐focused interview is used to elicit specific information in order to identify a disease or problem. Evidence suggests that patients are best served by integrating the two styles as the combination of the two approaches conveys the caring attributes of respect, empathy, humility and sensitivity (Fortin et al. [29], Haidet and Paterniti [35]). The interview should be open ended, drawing on a range of techniques to cue patients to tell their stories; active listening, guided questioning, non‐verbal affirmation, empathetic responses, validation and reassurance are all useful tools (Bickley and Szilagyi [9]).

Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment. For an initial assessment, these observations may include vital signs, physical signs and symptoms, and laboratory results. These are all measurable and objective.

Physical examination is a systematic assessment of all body systems and is concerned with identifying strengths and deficits in the patient's functional abilities. Physical examination elicits both objective and subjective data as it combines elements of both interviewing and observation. It is important to remember that physical examination can be viewed with some anxiety as patients can feel vulnerable, exposed and apprehensive. Good communication (both verbal and non‐verbal), together with observational skills, is key, as are ensuring that the environment is appropriate and that all required equipment is readily available.