History Taking | Part One

History Taking – Part One

History comes from a variety of sources:

  • Patient
  • Family
  • Friends, Bystanders
  • Law Enforcement

Weigh reliability of what they are telling you based on:

  • Mental Status, memory,
  • whether they trust you
  • whether they have something to gain

Techniques of History Taking

  • Setting the stage: needs to be the proper environment, put patient in ambulance if that is more private. Stay 2-3 feet away, shake hands, take notes unobtrusively
  • Open Ended vs. Closed ended Questions: each have their place
    • Tell me about the pain.
    • Do you have pain now?
    • What changes your discomfort?
    • Does it hurt when you breathe?
  • CC: Chief Compliant: main part if the health history and identifies in the patient’s own words, the symptoms for which the patient is seeking medical care:
    • Why did you call the ambulance today?
    • Facilitation = “Go on” “I’m listening” maintain eye contact –
    • Reflection = repeat what you’ve heard
    • Clarification = get more detail on the important points
    • Empathetic response = “You sound upset” “That must hurt a lot” – Confrontation = occasionally useful to reel them back in
    • Interpretation = synthesize what you’ve been told

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