HISTORY TAKING

DR. SAMAH MOHAMMED

EMS 351 Lecture (4)

2016 - 2017

Learning Objectives

1. List purpose of taking history.

2. Explain sample history.

3. Discuss way of past history.

4. Explain techniques of therapeutic

communication.

History Taking

• The purpose of obtaining a history is to:

1. Gather a systematic account of past medical

conditions, illnesses, and injuries.

2. Determine the events leading up to the

present medical situation.3. Determine the signs and symptoms of the

current condition.

History TakingGain information about the patient and the events:

1) Investigation of the chief complaint.

2) Mechanism of injury/nature of illness.

3) Past medical history.

4) Components of the patient history.

5) Interviewing techniques.

6) How to integrate therapeutic communication techniques.

Chief complaint

• The patient chief complaint is the most serious thing.– Should be recorded in patient’s own words.– Should include: • What is wrong.• Why treatment is being.

Sample history – Sample history includes

Signs / Symptoms

Allergies

Medications

Pertinent Past History

Last Oral Intake

Events (injury/ illness)

Sample History 1. Signs / Symptoms:• What signs and symptoms occurred at the onset of the

incident? Does the patient report pain?

2. Allergies:• Is the patient allergic to any medication, food, or other

substance? What is reaction?

3. Medications:• What medication is patient prescribed? What

dosage is prescribed? How often does the patient take medication?

Sample History 4. Pertinent Past History:

• Does the patient have any history of medical,

surgical , trauma? Has patient fall, , illness?5. Last Oral Intake:

• When patient last eat or drink? What did patient

eat or drink? Does patient take any drugs or

alcohol?

Sample History 6. Events (injury –illness):Can be assessment of pain is the OPQRST 7. Onset: when did the problem begin and what caused it?

8. Provocation: Does any thing make it feel better or worse? How are

you most comfortable

9. Quality: what is the pain like? And describe the pain?

10. Region/radiation/ referral: where does it hurt? Does the pain move

anywhere?

11. Severity: on a scale of 1 to 10, how would you rate your pain?

12. Timing: how long have you had the pain? When did the pain start?

Past medical history

– Should include:

1. Current medications and dosages.

2. Allergies.

3. Childhood illnesses.

4. Adult illnesses.

5. Past surgeries.

6. Past hospitalizations and disabilities.

1. Alcohol and drugs

Signs may be confusing, hidden.

History may be unreliable

2. Physical abuse or violence

Report all physical abuse or violence.

Follow local protocols.

3. Sexual history Ask all patients about the potential

for sexually transmitted diseases.

Taking History on Critical Topics

TAKING HISTORY Social history

1. Smoking habits.2. Alcohol and drug use , Sexual habits.3. Diet, Occupation , Environment.

Family history1. Helps establish patterned and risk factors for potential

diseases.2. Information should be related to the patient’s current

medical condition. Current health status

1. together past history with history of current event.

Techniques for History TakingAppearance

i. Clean, neat, and professional.

ii. Good attitude

iii. Identify your service and certification level.

iv. Try to interview in a private setting.Note taking

I. Let the patient know that you will be writing information down.

II. Position yourself at eye level. III. Maintain good eye contact.

Privacy a) Be familiar with relevant laws.b) Be familiar with the cultural groups in area.

Reviewing medical history and information reliabilitya) Document the source of all information.b) During routine transfers, look over paperwork.c) Evaluate your sources for reliability.

Techniques for History Taking

1. Empathetic response Put yourself in the

patient’s.2. Encourage dialogue.

Encourage the patient to express his feeling.

3. Ask about feelings. Tired, depressed, etc. Validate the patient’s

feelings.

Communication Techniques

Communication Techniques• Getting more information

1. Question location of pain.

2. Question quality of abdominal pain.

3. Add, delete, and modify questions.

4. Avoid close-ended and leading questions.

5. Try to be orderly and systematic. • Asking direct questions

1. If you need a date, time, etc., ask for it

Communication Techniques• Applying clinical reasoning

I. Critical thinking consists of:a) Concept formationb) Data interpretationc) Application of principlesd) Reflection in actione) Reflection on action

II. Think and perform well under pressure.III. Be a patient listener.IV. Communicate with patients.V. Look for nonverbal communication