History Taking Flashcards
Acronym used for history taking
OLDCART
What does OLDCART stand for?
Onset (when and what was happening at that time)
Location and radiation (Where and how far spread)
Duration (how long)
Characteristic (describe pain (sharp, dull, stabbing)
Associated factors (signs and symptoms present since)
Relieving/aggravating factors (better or worse)
Treatment (tried, stopped, seen other HCP)
What is the purpose of taking a patients history?
- Collect subjective info
- Active listening
- 70-80% diagnoses obtained in history
- Access for red-flags
- Establish rapport and build trust
- Identify underlying worries and concerns
- Inform physical assessment
How should you prepare to take a history?
-Ensure environment is appropriate
- Ensure you look appropriate and approachable
- Review any prior relevant documentation eg. Nursing notes
- Cultural considerations
What are some strategies for initiating communication and building rapport with patients/
- Introduce self and identify professional role
- Identify how patient would like to be addressed
- Check demographic detail
- Gain consent and clarify boundary of condifentiality
- Establish reason for gathering info to help set agenda eg. Admission and reported pain
- Be mindful of culture and language
What is the aim of ICE?
Aim to explore patients perspective at beginning of info gathering process – allow insight of health problem (eg. Come in wanting antibiotics)
What does ICE stand for?
I – Ideas – what they think is causing the problem?
C – concerns – Anything youre worried about in particular?
E – expectations – what do you hope to get out of today? – any thoughts about how to tackle the issue.
Give a lost of essential content to explore in getting a comprehensive history and background information
- Presenting problem – OLDCART
- Past medical history (other admissions to hospital or other HCP, long term health conditions, Immunisations and vaccines, illnesses/injuries as infant, child and teenager)
- Medication history – prescribed, non-prescribed especially over the counter and different route of administration
- Allergies – and ask what symptoms to these allergies and what treatment is given
- Personal and social history – eg. Smoking (how much), alcohol (how many units recommended 14 units), recreational drugs, occupation, accommodations and living conditions, sleep, nutrition, mobility, stressors exercise, hobbies and interests
- Family history – prior/current health of household
- Mental health – memory, stress/anxiety prior treatment
- Allow patient to ask you questions.
- Summarise plan of care or plan of action
- Ensure red flags are appropriately reported or escalated
What are some red flags that can be identified in history taking?
- Concerns cropping up in history taking
- Mental health (give support before discharge)
- Function (weaknesses)
- Pain
- Loss of consciousness dizziness
- Haemoptysis matochezia
- Unintentional weight loss
- Melena and hematochezia
- Change in lesions eg. Rashes
- Changes in mood eg. Hallucinations or suicidal thoughts
What is an acronym for effective communication?
SOLER
explain the acronym SOLER for effective communication skills
S- sit sequarely
O - Open posture
L - Lean forward
E - Eye contact
R - Relax
- Active listening
- Verbal and non-verbal
- Open and closed questions
- Prompts and probes
- Use transitions
- Ask questions that elicit graded response
- Ask one question at a time
- Offer multiple choice questions
What are some characteristics of effective communication?
- Facilitation – help move them through eg. Uhuh
- Silence
- Reflection
- Empathy
- Clarification – what they know about the condition, treatment
- Confrontation – check the info they are giving to you
- Summary – double check with patient
What does evidence show is improved with good communication skills?
- Increased understanding and recall
- Increased adherence
- Increased symptom relief
- Increased physiological outcome
- Increased patient safety
- Increase practitioner satisfaction
- Decreasing cost, complaints and malpractice litigation
