History Taking Flashcards
What are the 3 basic parts to a history?
1. biomedical data:
- the history of the presenting complaint
2. patient’s perspective:
- use ICE - ideas, concerns and expectations of the patient
- the impact the illness has on their life
3. the context:
- social history, past medical history, drugs and allergies
What are the 5 stages in the Calgary Cambridge model used in history taking?
- initiating the session
- gathering information
- physical examination
- explanation and planning
- closing the session
What should be conducted when initiating the session, according to the Calgary Cambridge model?
- preparation
- establishing initial rapport
- identifying the reasons for the consultation
What should be conducted during the ‘gathering information’ stage of the Calgary Cambridge model?
exploration of the patient’s problems to discover the:
- biomedical perspective
- patient’s perspective
- background information - context
What is involved in the explanationa and planning stage of the Calgary Cambridge model?
- providing the correct type and amount of information
- aiding accurate recall and understanding
- achieving a shared understanding by incorporating the patient’s illness framework
- planning and shared decision making
How should the session be closed according to the Calgary Cambridge model?
- ensuring an appropriate point of closure
- forward planning
Throughout the consultation, how should ‘building the relationship’ and ‘providing structure’ be acheived?
building the relationship:
- using appropriate non-verbal behaviour
- developing rapport
- involving the patient
providing structure:
- attending to flow
- making organisation overt
In general, what should be acheived when exploring the history of presenting complaint?
What is very important to establish before this stage?
you need to clearly understand the patient’s presenting symptom(s)
encourage and support the patient to tell their story by firstly building a rapport with them
once you have confirmed the list of symptoms, fully explore each one
How can you be prepared before beginning to take a history?
review the notes and any results available
How can rapport be established before commencing a consultation?
introduce yourself and check the patient’s identity
explain your role to the patient and what you are planning to do
agree the purpose of the consultation
What types of questions could be asked to identify the patient’s problem and seek their view of the problem?
“what problems have brought you to see me today?”
“what would you like to discuss with me?”
don’t assume that a patient with a mental health condition is here for that reason, it may be a physical health problem
How can listening without interrupting be acheived?
through active listening techniques
do not interrupt the patient and recognise cues from the patient and respond to them
After the patient has told you what their problem is, what should you confirm?
confirm the list of their problems and check for further problems
e.g. “you’ve been breathless and tired, is there anything else?”
What types of questions can be asked to explore the patient’s problem fully?
- ask them to start from the beginning of the symptoms
e. g “when did you last feel well”? - use phrases such as “can you tell me more about that” and “what happened next”
- encourage the patient to give their perspective
“how did you feel when that happened?”
When clarifying the symptoms that the patient has told you, what 4 areas should be covered?
- clarify the meaning of the symptoms
- clarify the duration of the symptoms
- clarify if there were any pre-existing symptoms and the relationship to these
- clarify the severity of the symptoms
(e. g. SOCRATES for pain)
