History Taking Flashcards
Chief complaint
Primary medical problem as defined by the patient.
- Focuses the clinical history towards the single most important issue
Chronology
Time element of the history, usually included the onset, duration, frequency and course of the symptoms
Clinical history
Information available regarding a patient’s condition
What is a clinical history comprised of?
Localization, Quality, Quantity, Chronology, Setting, Aggravating or Alleviating factors, and associated manifestations
Leading questions
Undesirable method of questioning; provides information that may direct answers toward a suggested symptom
Localization
The exact area of the complaint
Objective
Perceptible to the external senses
Quality
Description of the character of symptoms; color, quantity and consistency of blood or size or number of lumps/lesions
Subjective
Pertaining to or perceived only by the affected individual and not perceptible to the senses
What are the 3 main roles of the radiographer?
- Obtain a clinical history to assist the radiologist in diagnosing
- To record information on the requisition
- Check all information on the requisition for accuracy
What is the x-ray requisition?
The formal order for a diagnostic procedure and is a medical legal document
What information is included on a X-ray requisition?
- Patient Name
- Sex of patient
- Diagnosis (Dx) and pertinent clinical history (Hx)
- Date of exam and date when arrived
- Date of Birth (DOB)
- Signature of the requesting physician
- Pregnancy status and LMP (last menstrual period)
- Medical record number and insurance information
How to greet a patient?
- First introduce yourself and explain you’re the radiographer
- Ask the patient their name and check wristband for inpatient
- Always address patient by their last name, Mr or Mrs
What are the important features of interviewing a patient?
- Speaking slowly and clearly
- Listening to the patient
- Maintaining eye contact
- Using language the patient can understand
- Only asking one question at a time
What are patient interview Do’s?
- Ask open-ended, non-leading questions - to let the patient tell their story
- Facilitation (nodding, saying yes or no) - to encourage elaboration
- Silence (giving patient time to remember) - facilitates accuracy and elaboration
- Probing questions (to focus the interview)
- Repetition (rewording) clarifies information
- Summarization (condensing) verifies accuracy
What are patient interviews Don’ts?
- Do not ask personal questions
What are features of Objective Data?
- Perceptible to the senses
- Signs that can be seen, heard, felt
- Able to be measured
- Often physiologic
What are features of subjective data?
- Patient feeling
- Pain level
- Attitude
- Opinion of the observer
- Subject to interpretation
What are elements of a clinical history?
- Chief complaint
What are the sacred seven?
- Localization
- Chronology
- Quality
- Severity
- Onset
- Aggravating or alleviating factors
- Associated manifestations
Severity
The intensity and quantity of the symptom
Onset
When the symptoms began
Aggravating or alleviating factors
What makes the symptoms worse or better
Associated manifestations
Any other symptoms that accompany the chief complaint
What is informed consent?
Also called valid consent, and is a full explanation of the procedure including risks and benefits
What are the conditions for informed consent?
- patient must be mentally competent and of legal aged to make an informed consent
- consent must be voluntary
- consent must be signed by the parent or guardian
- explanation of the procedure must be in terms that the patient understands
What is implied consent?
Provides care when the patient is unconscious, and is based on the assumption that the patient would approve if conscious
What is simple consent?
Patient agrees with no explanation
