The document discusses principles and techniques for conducting an effective patient assessment through history taking, including establishing rapport, asking open and closed-ended questions, actively listening, gathering information on chief complaints, past medical history, current health status, and conducting a review of systems to identify any other issues. It also addresses challenges that may be present during history taking and provides guidance on overcoming communication barriers.

1. PARAMEDIC CARE:
PRINCIPLES &
PRACTICE

2. Patient
Assessment

3. The History

4. The ability to elicit a good
history lays the foundation
for good patient care.

5. Source of History
 Patient
 Family
 Friends
 Police
 Others

6. Setting the Stage
 If a patient’s chart is available,
review it before interviewing the
patient.
 Use this information to gain
clues about the patient.

7. Reliability
 Memory
 Trust
 Motivation

8. Patient Rapport

9. The First Impression
 Present yourself as a caring,
competent, and confident
health care professional.

10. When you introduce yourself to the patient,
shaking hands or offering a comforting touch
will help build trust.

11. Asking Questions
 Use a combination of open-
ended and close-ended
questions.

12. Language and Communication
 Use appropriate language.
 Use an appropriate level of
questioning, but do not appear
condescending.
 When encountering communication
barriers, try to enlist someone to
help.
 Actively listen.

13. Active Listening
 Facilitation
 Reflection
 Clarification
 Empathy
 Confrontation
 Interpretation
 Asking about feelings

14. Sensitive Topics
 A paramedic must learn to
become comfortable dealing
with sensitive topics.
 It is important to earn a
patient’s trust.

15. The Comprehensive
Patient History

16. Elements of the
Patient History

17. Preliminary Data
 Date and time
 Age
 Sex
 Race
 Birthplace
 Occupation

18. The Chief Complaint
 This is the pain, discomfort,
dysfunction that caused the
patient to request help.

19. The Present Illness
OPQRST-ASPN
 Onset of the  Associated
problem Symptoms
 Provocative/  Pertinent
Palliative factors Negatives
 Quality
 Region/Radiation
 Severity
 Time

20. Past History
 General state of health
 Childhood diseases
 Adult diseases
 Psychiatric illnesses
 Accidents or injuries
 Surgeries or hospitalizations

21. Current Health Status
(1 of 3)
 Current medications
 Allergies
 Tobacco
 Alcohol, drugs, and
related substances
 Diet
 Screening tests
 Immunizations

22. Current Health Status
(2 of 3)
 Sleep patterns
 Exercise and leisure activities
 Environmental hazards
 Use of safety measures
 Family history
 Home situation and
significant others
 Daily life

23. Current Health Status
(3 of 3)
 Important exercises
 Religious beliefs
 The patient’s outlook

24. You should take your patient’s
medications with you to the hospital,
when practical.

25. Review of Systems
 A system-by-system series of
questions designed to identify
problems your patient has not
already identified.

26. Systems
 General  Urinary
 Skin  Male/Female
 HEENT
 Respiratory
 Cardiac
 Gastro-Intestinal

27. Special Challenges (1 of 2)
 Silence  Depression
 Overly talkative  Sexually
patients attractive or
 Multiple seductive
symptoms patients
 Anxiety  Confusing
behaviors or
symptoms

28. Special Challenges (2 of 2)
 Patients  Limited
needing intelligence
reassurance  Language
 Anger and Barriers
hostility  Hearing
 Intoxication problems
 Crying  Blindness
 Talking with
families or
friends

29. If the patient cannot provide useful
information, gather it from family
or bystanders.

30. Summary
 History taking techniques
 Active listening
 The comprehensive health
history