Taking a History Flashcards
taking a history
first step of taking an injury/illness evaluation
history
info described by SA about what’s going on
more subjective info attained => find root. of problem
“history taking” acronym
Onset of events Provocation/palliation Quality with pain Region & radiation Severity Time
Onset of events
event (acute/chronic) => pain
“o” questions
what were u doing when you first noticed pain?
was there a specific event that caused pain?
Provocation/palliation
movement/ pressure/ alleviation
method making problem better/ worse
“p” questions
anything that helps alleviate the pain?
does stretching/ running/ throwing make pain better/ worse?
icing/ pain meds?
Quality of Pain
pain type (sharp, dull, achy, burning, constant, throbbing) thus type => better idea of problem
“q” questions
can you describe pain?
sharp pain w/ any specific movement?
burning, numbness, tingling => possibly neural issues!
Region & Radiation
specific location of problem => affected structures
“r” questions
can you point w/ finger where it hurts most?
or the general area?
Severity of Pain
how bad is pain using scale
- how debilitating pain is
- assessment tool for treatment effectiveness
”s” questions
can you rate pain from scale from 0 to 10?
0 = no pain –> 10 = hospital rn
Time
duration of pain since onset & if its changed (better or worse)
“t” question
when did pain start?
is pain constant?
has pain changed since u noticed it?
after taking a history (& importance)
ask if there is anything else SA would like to add (before moving onto objective info)
additional missing info; show we are listening; build trust between clinician & SA
other important questions
have you had same before this mvmet?
can you play thru pain?
goal with managing this issue?
did you see anyone else about this problem? what did they say?
if stretching helps pain, how is pain before/ after scale (1-10)?
family w/ similar issue?
