Patient history taking

Question 1

What are 4 steps in the Calgary-Cambridge model of taking a patient history?

Answer 1

1. Initiate the session
2. Gather information
3. Physical examination (if required)
4. Explanation and planning

Question 2

What is involved in the ‘initiate the session’ step of the Calgary-Cambridge model?

Answer 2

1) Initial rapport-
a) Introduce yourself
b) Ask the patient’s name
c) Describe why you are here
d) Ask if it is ok if you take notes?
2) Identify reasons for consultation-
a) Ask appropriate question (“What you you like to discuss today?”)
b) Listen attentively and do not interrupt
c) Confirm list of problems, screen for further problems (“So that is headaches and tiredness, is there anything else?”)

Question 3

What is involved in the ‘gathering information’ step of the Calgary-Cambridge model?

Answer 3

1) Explore the problem identified
a) Ask the patient to tell the story from first presentation in their own words (facilitate by repetition and paraphrasing)
b) If appropriate, ask about past medical history and drug history
c) Clarify any unclear or ambiguous statements (“Can you explain what you mean by light-headed?”)

Question 4

What is involved in the ‘explanation and planning’ step of the Calgary-Cambridge model?

Answer 4

1) Provide the correct amount and type of information
2) Aid accurate recall and understanding (use repetition, concise, avoid jargon)
3) Achieve a shared understanding incorporating the patient’s illness framework
4) planning- shared decision making
a) make suggestions rather than directives
b) offer choices
c) check that the patient agrees with the plan

Ask if they have any more questions before closing the session