Patient-centered Medical History Taking

Trevino A. PakasiDept of Community Medicine

Faculty of Medicine Universitas Indonesia

Objectives

At the end of the session, students will be able:• To take medical history based on the patient’s

needs• To take medical history according to the

standard procedure• To withdraw hypothesis or synthesize

individual health problems based on the medical history taking

Outline of the course

• Introduction lecture• Practicing

What you’ve learned?

• Empathy• Humaniora• Communication skill• Interpersonal relation skill

The patient-centered clinical method. Sumber : Stewart et. Al.(1995)

Disease

Illness

Context

Physical,History, lab

Ideas, expectations,

feelings, effect on function

Person

Problems

Goals

Roles

Finding common ground

Mutual decision

Enhancing the patient-doctor

relationship

Incorporating prevention and

health promotion

Being realistic

Patient presents

cues

Exploring both the disease and illness

experience

Understanding the whole person

Disease

Illness

Medical History

Purpose of history taking:• Understanding of the complain• Understanding the patient’s feeling• Understanding the symptoms or illness when

exists• Hypothesis of problems and possible cause

General Procedure• Verification of the patient’s identity• Reason for visiting the physician• Chief complain of illness when occured• Other related symptoms if any• History of the current problems• Pass medical problems related with the current

problems• Other medical history that might be important• Family medical history• Specific questions

Verification of identity

• Full name• Age or date of birth • Address• Background of the patients: formal education,

working, insurance coverage

Remember to start the conversation by interpersonal touch!

Reason of visiting

• Usually patient’s visit regarding his/her concern of any existing health problems / presence of illness

• Patient’s goal to be healthy• Patient’s goal to reduce risk

Formulation of medical history

• Identity• Chief complain / reason to visit• Other related symptoms • History of the current problems• Pass medical problems• Medical history in the family

Specific question

• For example in pediatrics patient: history of birth, lactation, immunization, growth and development

• For example in obstetrics patient: menarche, monthly cycle

• For example in eldery: daily activity at home• For example in psychiatrics: pre morbid

condition, personality

Specific question in family medicine service

Related with the family:• Family tree• Family cycle• Functioning in the family• Culture and habbits in the family• Housing and environment

Formulation of holistic diagnosis

• Aspect 1: patient’s concerned, knowledge, perceiveness, worries

• Aspect 2: clinical / medical problems – POMR• Aspect 3: internal factors• Aspect 4: external factors• Aspect 5: disability score