More Related Content
What's hot
What's hot (20)
Similar to History taking for nurses
Similar to History taking for nurses (20)
Recently uploaded
Recently uploaded (20)
History taking for nurses
- 1. History Taking Nazia Noreen/Nursing Instructor SON,LRH
- 2. Objectives Be able to: Understand the importance of the medical history Identify the relevant processes involved in taking a medical history Recognize the importance of structure in a systematic approach to history taking Understand the importance of ‘red flags’ Be able to take a systematic, comprehensive history from a patient
- 3. WHY “Without a good history it is an inevitable fact that the patient’s problem will remain undiagnosed, despite examination findings and the results of investigations that follow” is arguably the most important aspect of patient assessment, and is increasingly being undertaken by health professionals other than doctors (Fishman & Fishman 2005)
- 4. Why do we take history from the patient? 80% of diagnoses in general medical clinics are based on the interview (Epstein et al 2003) 76% correct diagnosis after taking a clinical history only (Peterson et al 1992) 83 % of doctors made correct diagnosis on the basis of medical history only (Hampton et al 1975)
- 5. What is the purpose of the ‘medical interview?’ To identify ‘problems’. To explore the health/illness of the patient To plan for the next step
- 6. History Taking - Assets Being empathic Being attentive Being articulate Being friendly but business like Being interested Environment! Introduce yourself Ask permission to take the history Have you got the correct person!! Patients Demographics
- 7. General Principles Let the patient tell their story Listen Develop a rapport, be friendly Be interested Use eye contact Use appropriate language and terms
- 8. Utilizing a structured interview process: Calgary-Cambridge Model. Initiating the session Gathering information Physical examination Explanation and planning Closing the session
- 10. Components of the History The present complaint The history of the present complaint Remaining questions of abnormal system Review of systems Past medical history Past surgical history Drug history Immunizations Family history Social history & habits
- 11. Set the Agenda Use open-ended questions initially Negotiate a list of all issues - avoid detail! Presenting complaint(s) and other concerns Specific requests (i.e. medication refills) Clarify the patient's ideas, concerns expectations (ICE) "Why now?"
- 12. History Taking Allow the patient time to tell the story in their own words. If you don’t understand something imply the problem is yours! If you are unsure about the main problem – “If I could make just one thing better what would it be?”
- 13. History Taking Pitfalls The patient does not always know what is and what is not relevant Hence the importance of a systematic enquiry The patient has an almost universal tendency to describe his/her symptoms not directly but in terms of what he/she thinks they are due to e.g. Neuritis, Rheumatism What do you mean by?
- 14. History Taking Examples of techniques Open enquiries e.g. Tell me about your pain? How did you react to the tragedy? Closed inquiries When did your pain begin?
- 15. History Taking Examples of techniques Open enquiries e.g. Tell me about your pain? How did you react to the tragedy? Closed inquiries When did your pain begin?
- 16. History Taking Precision is important, questions such as: Q. “Do you ever get breathless?” are totally useless without qualification
- 17. Structure Presenting Complaint History of Presenting Complaint Past medical history Drugs (medications/allergies) Family history System enquiry Social history
- 18. History Taking Open questions Clarification Reflection - involves putting back to the patient a symptom or remark Summary - an expansion on reflection
- 19. Hist Direct Questioningory Taking Sequence of events How things are currently Other symptoms Associated with possible differential diagnosis In the same system as main presenting symptom Important negatives Risk factors
- 20. Key points What to ask and how to ask it Open ended questions are better than closed questions in establishing framework of the history Closed questions provide detail and sharpen the account Keep the history flowing Minimum of interruptions Use reflection and summary when appropriate Use the patient’s own words Avoid technical terms
- 21. Secondary History Expands on the primary history, especially any associated symptoms. These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder.
- 22. Past Medical History Open questions What illnesses have you had? (include psychiatric conditions if appropriate)
- 24. Drug History Not just prescribed drugs - include over the counter remedies and alternative medicine Name each substance, dose and duration Compliance Drug allergies & sensitivities
- 25. Medication and Allergies Medication Generic name if possible Dose Route of administration Recent change Include OTC and homeopathic / herbal Recreational drugs Allergies & Sensitivities When? Diagnosed? How presented, symptoms
- 26. History Taking Family history Open question - ‘tell me about any illness(es) which run in the family Ask specifically about immediate family including parents Diagnosis and age Cause of death
- 27. Social History Family situation Relationships incl. Marital status Occupation Past and present Exposure Community Involvement & Network Hobbies
- 28. Social History Alcohol history Quantity and type Place of drinking Alone or accompanied Money spent Purpose
- 29. Social History Tobacco Duration Type - pipe, cigarettes, cigars Amount If stopped when
- 31. Systematic Inquiry Direct questioning Organise symptoms by system Explore any positives with open ended questions and then clarify as per presenting complaint Use lay terms Summarise Anything else?
- 32. Systematic Inquiry C.V.S. Chest pain Breathlessness On exertion Lying flat Wake up at night Orthopnoea Palpitations Ankle swelling Exercise Tolerance Pain in legs when walking
- 33. Systematic Inquiry R.S. Shortness of breath Chest pain On inspiration Cough Sputum Blood Wheeze
- 34. Systematic Inquiry GI System Dental / Gum Problems Reduced appetite/weight loss Swallowing painful difficult Indigestion, heartburn Abdominal pain Vomiting Altered bowel habit Blood loss
- 35. Systematic Inquiry Urogenital Pain on passing urine Frequency - day, night Colour of urine Males: (age), difficulty starting, poor stream, dribbling, discharge, libido Females: menarche, menopause, frequency, regularity, urge or stress, incontinence, discharge, abnormal bleeding, libido
- 36. Systematic Inquiry CNS Weakness Disturbance of sensation Headaches Visual disturbance Dizziness, blackouts (clarify these) Fits Confusion Disturbance of speech Hearing
- 37. Systematic Inquiry Locomotor Joint Pain Joint Stiffness Swelling Mobility Gait Falls Redness and warmth
- 38. Systematic Inquiry Endocrine Heat intolerance (change) Cold intolerance (change) Change in sweating Thirst and Polyuria Prominence of eyes (change) Swelling in neck Energy
- 40. Systematic Inquiry Sleep and rest
- 41. Summary Salient features of Presenting history Relevant past history Background Differential diagnosis
- 42. Summary Explanation Most important from the patients point of view Communication skills are vital Speak clearly and audibly Avoid jargon Avoid emotive words Most important information first
- 43. REFERENCES Quilliam, S. (2011). "'The Cringe Report': Why patients don't dare ask questions, and what we can do about that". Journal of Family Planning and Reproductive Health Care. 37 (2): 110–2. doi:10.1136/jfprhc.2011.0060. PMID 21454267. Mayne, JG; Weksel, W; Sholtz, PN (1968). "Toward automating the medical history". Mayo Clinic Proceedings. 43 (1): 1–25. PMID 5635452. Cash-Gibson, Lucinda; Pappas, Yannis; Car, Josip (2012). "Computer-assisted versus oral- and-written history taking for the management of cardiovascular disease". In Car, Josip (ed.). Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD009751. (Retracted, see doi:10.1002/14651858.cd009751.pub2. If this is an intentional citation to a retracted paper, please replace {{Retracted}} with {{Retracted|intentional=yes}}.) Tideman, R L; Chen, M Y; Pitts, M K; Ginige, S; Slaney, M; Fairley, C K (2006). "A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting". Sexually Transmitted Infections. 83 (1): 52–6. doi:10.1136/sti.2006.020776. PMC 2598599. PMID 17098771.