Part 1

If you’re a pharmacist or a nurse, or maybe you’re a student, and you’re planning to deal with patients and gather information for patients, then you have to make sure that your history taking is timely, effective, efficient, and accurate. And in this video, that’s exactly what we’re going to start to look at.

Now, before we go any further, in order for you to unlock your potential, and be a better version of yourself, be part of the medical community. And together we can build a better world.

What is a patient history?

Well, you can think of a patient history as a patient interview, or rather an interview. And this is where you’re gathering information from the patient, with the aim to identify what is causing the patient’s symptoms.

Why is history taking important?

Remember, patients present with signs and symptoms, patients don’t usually present with a diagnosis. So it is your responsibility to gather that information, make sure it’s accurate, and be able to identify what is causing the patient’s symptoms.

How do you relate the history to the examination?

Well, the key thing to understand is that it’s your patient’s history that guides the examination. For example, if you have a patient who presents with chest pain, it would not be efficient for you to undertake a physical examination of the cardiovascular system, respiratory system or musculoskeletal system. There’s no art in that. There’s no skill in that. But if you could gather the patient history, identify the differentials and then utilize that information to be able to guide your physical examination, then you’re on the right track. So as a summary, your patient history is what would help you to identify the cause and what’s rather the disease that is manifested in the patient and causing the patient symptoms. Thank you

Part 2

We’re going to start to look at how you can take a patient history safely, efficiently, accurately, and make sure that every time you’re adding value to your patients. Now before we go any further, become part of the MEDLRN community. And together, let’s unlock your potential and let’s build a better world.

What are my key steps?

Step number 1, Introduce Yourself

Always introduce yourself, explain to the patient your title, and that way, you can ensure that you’re building a relationship and your consultation is moving in the right direction, and it also prevents misunderstandings.

Step number 2, Gather Information

Gather patient information. Make sure that all the information that you gather from the name, address, contact number, date of birth, gender is up to date.

Step number 3, How they would like to be addressed

Ask the patient how they would like to be addressed. Again, this is very important to ensure that your consultation is moving in the right direction and you’re building rapport with your patient, and also your patient feels at ease. Another tip is to explain to your patient that any conversation you’re having is confidential.

Step number 4

Make sure when necessary, you have a chaperone in place. This is for your safety, but also for the safety of the patient.

Step number 5 Layer roadmap.

Layer roadmap. Explain to the patient exactly what to expect within this consultation. Inform them that initially, you’re going to be giving them an opportunity to explain what’s wrong. You’re going to be writing notes and you’re not ignoring them. But also you may need to ask further questions about their signs and symptoms. But also take a general outlook and ask questions generally about their health to help them and help you identify exactly what the problem is.

Step number 6, start gathering the history.

Now, remember, always make sure that you document appropriately, including what your findings are, but also the negative findings. That way you’re not set up to date and everything moving in the right direction.

Thank you