Overview
What Is History-Taking?
Patient history-taking is also referred to as anamnesis. It is one of the most crucial aspects in the assessment, evaluation and management of patients in health care settings and even those undergoing home-based care. Obtaining relevant patient history is the first step in every examination of a patient. Therefore, history-taking is more of an art.
Taking history from a patient is not only about obtaining information but also building a rapport and strong therapeutic relationship between the healthcare practitioner and the individual being assessed.
Sources of data in history taking can be;
- Self
- Guardian- where the patient is a child
- Informant- in cases where the patient cannot speak up fr themselves due to several issues such as mental health.
Also, an informant can be use to validate information given by the patient himself/ herself.
Proper history-taking is highly advocated for. This can help to gather information from all areas concerning the life of the individual patient thus making diagnosis easier in some instances.
The Art of History-Taking
In most of the medical schools we attend, we are taught that the key to a proper diagnosis is to obtain relevant patient history. Good communication skills are needed by the medical practitioner so as to gather all relevant details. It is important to let the patient know the whole procedure of history-taking and its importance. This can help in thatthey will not view your questions as irrelevant in relation to their present condition. Mostly, patients present at the hospital or healthcare facility to search for treatment and cure to their medical problems. Therefore, they are mostly concentrated on the end goal of the process which may be being told to go to the pharmacy and pick specific regimens for their condition.
As the patient anticipates a ptoper diagnosis to be made for them, it is important to let them know that their corporation and answering questions truthfully will contribute majorly to a proper diagnosis.
Therefore, a good healthcare practitioner must habe good communication skills that will enable them gather relevant information from the patient wthout straining the doctor-patient already-established relationship.
Also, ensure to listen properly to what a patient says and avoid stopping them before they finish.
Apply utilization of both open-ended and closed-ended questions appropriately.
Major & Relevant Parts
The following are the major parts in patient-history taking;
- Patient bio-data
- Chief complain/Presenting complaint
- History of presenting complaint
- Past medical history
- Medication history
- Family history
- Social history
- Functional enquiry/ systems review
We are going to discuss each of the parts.
Patient bio-data
- Full names- 2 or 3 names
- Their age, weight, sex, place of stay, date of admission and date of history taking are noted
- An informant may be needed to determine if the informaton said is true.
- The name of the informant is also noted down.
Chief complaint
- It is also known as the presenting complaint.
- Complaints are listed in chronological order, and in the informant’s/ patient’s own words
- It is just a simple sentence together with duration of the complaint.
- For example, chest pain for 4/7
History of Presenting Illness
Patient gives a detailed description of events that led to chief complaints
Pat Medical History
Note down all previous hospitalizations together with reasons for hospitalization, investigations done and surgeries performed
Check if any of the mentioned medical history relates to chief complaint and enquire further if affirmative
Family History
- Details of which born are obtained. For example, first born, last born.
- Number of children in the nuclear family. How many are still alive and well (a&w?)
- Inquire about parents/ guardians
- For paediatrics/children, learn whether parents are together or separated.
- Ask about the cause(s) of death of all close relatives
- The afflictions of the patient’s close relatives (e.g., diabetes, epilepsy, hypertension, alcoholism, stroke, TB, arthritis , heart disease, asthma, etc).
Social history
- Marital status
- Work and work place
- Level of education
- Place of habitation and surrounding conditions- source of water, sanitary conditions
- Sexual history
- Dietary history
- Drug Abuse history.
Medical & Drug history
- Ask if the patient is currently on any drugs
- Probe the reason for that prescription.
- Are they for the current chief complaint or other?
- The dosages of the medicines
- The duration of taking the medication
- Compliance
- Probe for possible drug side effects
- Drug Allergies – eg Penicillin
- Use of herbal remedies
Functional Enquiry
- A female doctor discusses the patient’s condition with him as part of history-taking.
- Questions designed to discover any problems that the patient forgot to mention or didn’t think they were important (e.g., “Do you have trouble seeing or hearing, problems with coughing or breathing, indigestion, or tremor?”).
- Ask questions systematically;
- CVS- Cardiovascular system
- CNS- Central nervous system
- RS- Respiratory system
- GIT- Gastro-intestinal system
- GUS- Genito-urinary system
- Musculoskeletal system
Summary
- Let the patient’s story flow freely
- Listen and listen carefully, jotting down relevant information.
- Note down what the patient thinks is wrong with them.
- Be open-minded and avoid making assumptions
- Mostly, employ open-ended questions and try as much as possible to avoid using leading questions.