PATIENT HISTORY TAKING

Patient History Taking



Table of Content

Introduction3

The Setting3

The Process4

Clinical competency5

Identifying the problems and concerns5

Exploration of the Patient's Problems6

Historical perspectives on clinical competence7

Determinants of clinical competence development8

The nature of clinical competence in patient history taking9

The development of clinical competence in patient history taking process11

Conclusion13

References14

Patient History Taking

Introduction

Good history taking is an important first step in treating the patient. Each person will develop their own style and technique, but a good interview will likely include the basic elements discussed below. Remember you are treating a patient, not their condition. The better you understand your patient, the better your treatment plan will be and the more likely you will be to get good patient compliance. The patient interview can be thought of as having two parts: (i) the setting for the interview and (ii) the interview process itself.

The Setting

The setting is important because it creates the environment in which you and the patient must interact. The environment will greatly influence how comfortable the patient feels during the process and how complete and informative the patient's answers will be. It is normal to expect patients to experience some degree of anxiety during an initial interview, if for no other reason than they are about to discuss personal matters with a stranger. If your approach is more like an interrogation, the patient will be closed and unresponsive to your questions. If your tone is judgmental, there is a chance that the patient will disregard you advice and instructions. In either case, the patient is very likely to seek another doctor. Patients want to feel comfortable and at ease when talking to their health care provider.

And they have a right to expect a pleasant and professional approach to their problems. If it is the first patient of the day this is easy, on the other hand, if it is the last patient after a horrible day, it may be easier said than done. Within limits you may be able to adjust your physical surrounding to facilitate good interviews. Try to avoid having a table or counter between you and the patient. A cold, sterile room is not conducive to discussing haemorrhoids, while a carnival-like atmosphere may not inspire the level of confidence you are seeking. Check your seating position - make sure your seating is no higher than eye level. Patients are very uncomfortable having to look up while talking and are actually most comfortable while looking slightly down. Be aware of your body language - avoid body positions that are defensive or withdrawn. Be aware of eye contact, too much and too little are both bad. Watch your vocabulary - don't overwhelm the patient with highly technical terminology they don't understand; at the same time, don't talk down to the patient. Lastly, a warm hand shake is a very comforting gesture towards a new patient and it's also a nice way to conclude the visit.

The Process

The questions are the key to a good interview. You need to use a mix of “open ...