How to take a patient history. - PowerPoint Presentation

How to take a patient history. Part 1 Chief complaint

Standard 10) Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through: History and Physical including but not limited to: family, environmental, social, and mental history Brief Head to Toe Assessment noting normal vs. abnormal findings Vital Signs Assessment (VS) Height/weight, BMI /Calculation Specimen Collection

First Impressions Medical professional’s role is to connect patient with physician or providerIncludes: checking vital signs and patient interview to obtain medical history Use effective communication Summarize interview when finished

Interviewing Techniques Closed questions Open-ended questions Directive statements Restating Reflecting Redirecting Active listening Silence Summarizing

The Talkative Patient Establish clear guidelines for the interviewMay have to redirect patient to specific interview questions Ask closed questions that require a “yes” or “no” answer To ensure accuracy of information, restate the information Redirect patient in kind, assertive manner

The Quiet Patient Quiet or shy, provide little informationAsk open-ended questions that require more than one- or two-word answers Practice wording questions ahead of time Use directive statements

Obstacles to Effective Interviewing Any medical provider other than a physician should refrain from offering medical advice Do not provide false reassurance Keep language and vocabulary professional and accurate Speak in terms the patient can understand, do not use medical jargon Take care not to imply judgment

Discussing Sensitive Topics Personal information such as sexual activity, use of birth control, number of sexual partners, bowel and bladder function, and menstrual pattern Provide privacy and patient comfort; allow patient to remain clothed Assure information will remain confidential Begin interview with general questions and end with more personal questions

Age-Appropriate Communication Adapt vocabulary and interviewing strategies appropriate to age of patient Children — sit at eye level to make eye contact Older children and adolescents — offer choices whenever possible Elderly — adapt for any sensory or perceptual deficits

Subjective vs Objective subjective ( sŭb-jek'tiv ) 1. Perceived only by the patient only and not evident to the examiner; said of certain symptoms, such as pain. 2. Colored by one's personal beliefs and attitudes. objective ( əb-jĕk′tĭv ) adj. 1. Based on observable phenomena; empirical. 2. Relating to or being an indicator of disease, such as a physical sign, laboratory test, or x-ray, that can be observed or verified by someone other than the person being evaluated.

S ubjective: what the patient s ays O bjective: what you o bserve.

How to Take a Medical History A medical history is a record of a patient’s condition, past and present. It documents: Physical or mental conditions of which the patient is aware. Major illnesses the patient may have suffered. Surgeries the patient may have undergone. A medical history also contains as much information as you can get about any pain, discomfort or other medical issues the patient may be experiencing. (HX of CC) The order in which you ask these questions will likely be determined by the doctor for whom you work. You will probably be given a form with these -- or similar -- questions in their preferred order.

Introduction Before you enter the room ____ _____ ____.Begin by introducing yourself and explaining you are helping the doctor by taking a medical history. Be as friendly and open with the patient as you can to establish rapport and build trust. It is important the patient feels comfortable with you because you need to get full, honest answers.

The Medical History Logistical data— DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings PMH (past medical history) — immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries FH (Family History) — information about parents, siblings, and children

The Medical History SH (Social History)— patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol ROS (Review of systems) — systematic collection of data regarding patient’s overall health

Documentation Patient’s chart is a legal document Documentation should be thorough, legible, and professional Do not document in pencil, do not use unapproved abbreviations, do not add late entries, make corrections following facility’s policy guidelines, document facts, and do not make assumptions

chief complaint (CC) Main complainta subjective statement made by a patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care. It is used most often in a health history.

When you enter the room Wash your handsIntroduce yourself in a friendly manner if you do not know the person . For example, say "Hi! I'm Joe Smith. I would like to ask you a few questions about your illness. Is that OK? You seem to be in pain. Can you tell me when it started?"

Explore the main problem in more detail. This can be summarized by the mnemonic O.P.Q.R.S.T.: Onset Palliation/Provocation/ Persistence Quality Symptoms/Severity Timing

Onset When did this pain start? How long has it been going on?

Palliation/Provocation/ Persistence: W hat makes it better? What makes it worse? Is the pain the same as when it began?

Quality What does it feel like?Describe your pain to me?Give examples Sharp, dull, stabbing, boring, digging in, throbbing, tight, numb…….

Region/Radiation Where is the pain? Does the pain travel anywhere? shooting, tingling

Symptoms/Severity What other feelings or sensations do you get? On a scale of 0 – 10, 0 being no pain 10 being the worst pain you have ever experienced, what number would you give your pain.

Timing Maintain the narrative thread. "What happened first? ...then what?..." Find out the context of the medical problem. " "Is the pain continuous, repeating, or sporadic?“ What time of day is it worse?

Basic Personal Information. Confirm the patient’s: name address phone number emergency contact

Current Complaint/ Chief Complaint Is the patient here today to address a specific complaint or just to get a periodic physical examination? If the patient has a current complaint, you need to get a full description of the issue. Questions to ask include: OPQRST Where is the problem located? What are the general symptoms? When did this problem begin? Has it changed over time? Does it affect any other areas of the body? Does it vary depending on time of day? Does anything make the symptoms better or worse? Does the problem interfere with daily activities or sleep?

Current/Past Illnesses and Conditions . Part of any medical history is a record of any major illnesses or conditions from which the patient currently suffers, or which the patient has had previously. Ask about any current conditions that have been diagnosed, including: Hypertension (high blood pressure) Diabetes Epilepsy Asthma Arthritis Depression Cancer Tuberculosis HIV/AIDS If the patient is female, is she pregnant? Ask about childhood illnesses, including: Measles Chicken pox Rubella (German measles) Mumps Also confirm all immunizations the patient has had, including vaccines for polio, tuberculosis and DTP (diphtheria, tetanus and pertussis), as well as the childhood diseases listed above.

Surgeries and Procedures Get the when’s and why’s about any past surgeries or other major medical procedures. Were they successful? Were there any complications? If the patient is over 50, did he/she ever have a colonoscopy? Patients will often forget about Dental procedures.

Current Symptoms Although the patient may have a specific complaint -- or no complaint at all -- you still want to look for signs of other conditions that may be contributing to the problem. Ask the patient if he/she is experiencing: Headaches Shortness of breath Chest pains Dizziness Blackouts Loss of appetite Swollen ankles Coughing Nausea/vomiting Recent changes in bowel habits Blood in the stool Pain or burning while passing urine Back pain Joint pain

Men Vs Women For men, you should ask about the presence of any penile discharge or problems with sexual functions. For women, ask about the presence of any vaginal discharges and frequency of menstrual cycles. If the patient is currently going through menopause, when did she experience her last period?

Obstetrics If your patient is female, you need to ask: Has she had any past pregnancies? If so, how many? Has she ever suffered any miscarriages? Were there any complications during pregnancy, such as hypertension, toxanemia (pre-eclampsia) or diabetes? Were the deliveries normal, or were C-sections required? If so, why? Has the patient ever had an abortion? If so, was it elective or for medical reasons?

Prescription Medications Ask the patient to list all prescription medications he/she is currently taking.

Lifestyle Many of our lifestyle choices directly -- or indirectly -- contribute to our health. You therefore want to ask your patient about: Marital status Average hours of sleep daily Tobacco use (now or in the past) Alcohol use (what and how often) Regular exercise (what and how often) Travels abroad (where and when) Diet Fried food Spicy food Red meat Dietary supplements Stress Recreational drug use (what and how often)

Family History Since many diseases and conditions run in families, ask the patient about: Parents -- alive or dead? If dead, how? Siblings -- alive or dead? If dead, how? Any genetic diseases known to be present in the family line.

Conclusion Complete by asking the patient if there are any other issues or concerns that you should note.

Melinda is a 22 year-old patient who has come to the clinic for the first time to establish care. She is quiet and sky and reluctant to disclose personal information. Her current chief complaint is pelvic discomfort and dysuria. You must obtain a complete health history, including information about sexual activity, birth control, menstrual pattern, and current symptoms. Describe some strategies that might be employed to put this patient at ease and obtain the necessary data

Gloria is a 69 year old patient at the doctor’s office for her annual checkup. She is friendly, talkative woman who loves to tell stories and gets easily sidetracked. She has multiple medical complaints and is eager to discuss them all at great length. A complete health history and evaluation of current complaints must be evaluated in a time-effective manner. Describe strategies that might be used to keep this patient on track.

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