Communication Smarter way. Ref : Family practice Management.May 1999 Interpreted by Rajeev Kashyap
Time constrain in Clinical research visit
Research documenting are time lined and demanding
Always start with the standard questions applied to the chief complaint(s):
Effect on Function
Repeat this series of questions for each chief complaint. Ask one question at a time; avoid multi-part questions.
Some questions won't work in certain situations, for example fatigue doesn't have a location.
Record the information as objectively as possible without interpretation. Avoid medical jargon unless the patient uses it.
Quote the patient directly as needed, "my nose itch," for example.
1. Patient Identification (ID)
2. Patient Profile (PP)
3. Chief Complaint (s)
4.the reason(s) Why the patient sought medical advice?
Review of Systems
History taking AIM
The aims of history taking are threefold:
To identify the relevant organ system(s) responsible for symptoms
To clarify the nature of the pathological processes at play
To characterize the social context of patients’ illness, their concerns,their interpretation of symptoms, beliefs and attributions and any limitations of daily activities consequent upon their illness.
The key to reaching an accurate diagnosis is obtaining a detailed description of the patient’s symptoms. Every individual symptom suggests a differential diagnosis which may initially be wide ranging but can be brought into sharper focus by obtaining as much detail as possible.
Approach to the patient
You will feel intimidated in your first attempts at history taking.
Try to be caring and compassionate but remember that you are not directly responsible for your patient’s medical care.
Introduce yourself with a friendly greeting, giving your name and status.
Explain the purpose of his/her visit, ask for and remember the patient’s name and request permission to interview and examine the patient.
Factors in establishing rapport
Introduce yourself in a warm, friendly manner.
Maintain good eye contact.
Facilitate verbally and non-verbally.
Touch patients appropriately.
Discuss patients’ personal concerns.
History Taking Techniques
Adopt a personal, conversational style rather than an interrogative approach and don’t confuse patients with medical jargon.
When asking specific questions relating to symptoms, avoid leading questions which might compromise the quality of information obtained.
History Taking Techniques(Cont.)
LISTEN:Allow patients to tell the story in their own words Encourage their flow with verbal and non-verbal cues Try not to interrupt
CLARIFY:Exact nature of vague terms or lay terms ,Timing of events
Apparent inconsistencies or gaps in the story.
QUESTION:Specific areas of relevance Use open questions initially
Avoid leading questions
SUMMARISE:Outline the story as you understand it Invite patient to correct inaccuracies
Top ten technique tips
Give the patient your undivided attention
Keep your note-taking to a minimum when the patient is talking
Use language which the patient can understand
Let patients tell their own story in their own way
Steer patients towards the relevant
Use open questions initially and specific (closed) questions later
Clarify the meaning of any lay terms or diagnoses patients use
Remember that the history includes events up to the day of interview
Summarize (reflect back) the story for the patient to check
Utilize all available sources of information
History taking Sequence
one effective and commonly used sequence
History of current illness
Past medical history
Drugs and allergies
Social and personal history
Patient’s ideas, concerns and expectations.
Introduce yourself to the patient giving your name
Ask the patient’s name,
Ask for permission to take a history
the principal symptom or symptoms that caused the patient to seek medical attention, when it first appeared and how it has changed over time.
When did you last feel fit and well?
• When did you first notice a change in your usual state of health?
• What was the first symptom you noticed?
• When was that and what has happened since?
• What else have you noticed about your health?
• What has happened to you since you came into hospital?
• How do you feel at the moment?
Record the presenting complaint in the patient’s own words,
the date and time of its first occurrence and
if the problem has changed in any way since its onset.