Exam 1 - History Taking and Documentation Skills Flashcards
Patients visit clinicians for various reasons (4):
- Well Checks - Annual physical exams, clearance for surgical procedure
- New acute problem - Sore throat, ear ache, influenza, cough, rash
- Continued treatment of an existing problem - HTN, DM, follow up on lab studies, cultures, biopsy results, cancer, pain management
- Post Operative follow up visits - Suture or staple removal, wound assessment
**Regardless of the reason for the visit
All patient visits must be documented properly
Patient-Centered Medical Model
- Everything you do for your patient revolves around your patient.
- Your patients picked you to take care of them, not the other way around.
- Keep the patient at the center of all your decisions.
- Always consider age, gender, ethnicity and genetics.
- Consider how you would want to be approached and how you would want to be taken care of.
- Always treat your patients with dignity and respect.
- Your medical decisions must be based upon what the patient desires
- It is not up to you to decide what is best for your patient
- Give your patient options to help them decide
- All decisions must be made with the patient in mind = patient-centered medical model
The job of the clinician is to:
- Determine what is wrong with the patient. What did the patient need?
- Efficiently evaluate, correctly diagnose - Come up with a plan that is pertinent and satisfactory to both clinician and patient.
- Provide health promotion and prevention
- Effectively treat
How do clinicians perform this job?
- Carefully listen to the patient.
- Ask pertinent questions to obtain details.
- Patient interview
- History taking - Perform relevant physical examination.
- Come up with a list of possible conditions or diseases the patient is suffering from.
- Differential Diagnosis (DDx)
- Order and interpret pertinent diagnostic studies.
- Decide “what” the patient is suffering from. - Diagnosis
- Provide a Plan of Action.
- Treatment
Differential Diagnosis (DDx)
Come up with a list of possible conditions or diseases the patient is suffering from.
Comprehensive Health History
Identifying data
Source of history
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMHx)
Family History (FHx)
Social History (SocHx)
Review of Systems (ROS)
Interviewing Skills
Empathetic listener
Ability to relate to patients of all ages
Non-judgmental, non-biased interviewing
Ethnicity and cultural considerations
Accommodation in interviews
Wheelchair bound? Mentally challenged?
Hearing deficit? Visually impaired?
Wearing oxygen? Depressed? Panic attack?
Is a care taker present? Recent loss of a loved one?
Techniques for interview progression
Show respect at all times; use Mr., Mrs., sir, ‘mam
Move in specified order
Ask focused but open-ended questions
Allow your patient to speak
Carefully observe your patient during the interview
Summarize what your patient has told you
- Ask “did I leave anything out?”
Observe patient to uncover signs and symptoms.
Conduct General Survey Establish environment of trust Gain the patient’s confidence Ask appropriate questions Learn as much as possible to lead to a list of things that could be happening (differential diagnosis)
Chief Complaint (CC)
Derive the CC easily with a simple, open-ended question.
“What brings you in today?”
“How can I help you today?”
The CC is typically disjointed.
Document the patient’s or caretaker’s own words and descriptions.
Always ask “left or right?”
History of Present Illness (HPI)
HPI = narrative of why the patient is being seen by you.
Documented in the patient’s own words.
Brief but detailed account.
Includes 7 basic attributes.
Describes symptoms the patient is experiencing.
HPI- 7 Basic Attributes
Location Quality Quantity/Severity Timing (onset, duration, frequency) Factors that aggravate Factors that relieve Associated symptoms (manifestations) per organ system
Past Medical History (PMHx)
Adult, then Childhood illnesses Past Surgical History (PSHx) OB/GYN History Psychiatric History Hospitalizations Health Maintenance ==>Immunizations ==>Screening Medications ==>Allergies to medications and environment ==>Side effects to medications
Family History (FHx)
- Narrative
- Pedigree- see Bates’ text p. 32; need 3 generations
Example: grandparents, parents, patient, children
