History Taking

Course overview

Objectives Explain the process and components of a patient assessment Describe how to effectively and thoroughly gather a patient history and how it can affect patient care Implement interview techniques that aid in building rapport with patients Content Information Covered Investigation of the Chief Complaint The chief complaint is a very brief description of the reason for summoning EMS to the scene Factors influencing the data collection What is the source of the information Patient usually the best source for information Family Friends Bystanders Public safety personnel Medical identification jewelry or other medical information sources How reliable is the data History of the present illness Detailed evaluation of the chief complaint Provides a full clear chronological account of the signs and symptoms Components of a Patient History Statistical and demographic Obtain correct dates Accurately document all times Identifying data Age Sex Race Past medical history pertinent to the medical event Medical Trauma Surgical Consider medical identification tag Current health status pertinent to the medical event Focuses on present state of health Environmental conditions Individual factors Current medications Allergies Tobacco use Alcohol drugs and related substances Diet Screening tests Immunizations Environmental hazards Use of safety measures in and out of the home Family history Techniques of history taking Setting the stage Environment personal space EMS personnel demeanor and appearance Be aware of body language Clean neat and professional Note taking Difficult to remember all details Most patients are comfortable with note taking Learning about the present illness Refer to the patient by name Refer to the patient by their last name with the proper title such as Mr Mrs or Ms If they inform you to address them by their first name do so Avoid unfamiliar or demeaning terms Determine chief complaint Use a general open ended question Follow the patients lead Facilitation Posture actions or words should encourage the patient to say more Making eye contact or using phrases such as go on or Im listening may help Reflection Repeating the patients words encourages additional responses Typically does not bias the story or interrupt the patients train of thought Clarification used to clarify ambiguous statements or words Empathetic responses use therapeutic communication to interpret feelings Confrontation some issues may require confronting patients about their feelings Interpretation requires making an inference History of the present illness Location where is it Onset when did it start Provocative palliative and positioning What makes it worse What makes it better What position is the patient comfortable in Quality what is it like Radiation does it move anywhere Severity Attempt to quantify pain Use a scale from one to ten Time Duration When did it start How long does it last Associated signs and symptoms Pertinent negatives For trauma patients determine the mechanism of injury Assess past medical history Pre existing medical conditions or surgeries Medications Allergies Family history Social and travel history Current health status Tobacco use Alcohol drug and substance use Diet Standardized approach to history taking SAMPLE history Signs and symptoms Allergies medication and environmental Medications over the counter prescribed vitamins herbal birth control erectile dysfunction and other peoples medications Past pertinent medical history Last oral intake fluids food and other substances Events leading to illness or injury OPQRST history Onset Provocative palliative and positioning Quality Radiation Severity Time Taking history on sensitive topics Alcohol and drugs Physical abuse or violence Sexual history Special challenges Silent patient Be alert for nonverbal clues Overly talkative patient summarize frequently Patient with multiple symptoms Anxious patient provide