Friday, 6 June 2008

history taking skills

Opening the Interview/Setting the Agenda

The Trouble with Physicians

In one study, physicians did not allow patients to complete their opening statements 69% of the time. The mean time until the first interruption was 18 seconds. Once interrupted, fewer than 2% of patients went on to complete their statements.

"Data are thus very much physician-determined, skewed toward problems that are biomedical in nature... It has been proposed that current interviewing practices are at odds with scientific requirements: They produce biased, incomplete data about the patient."

An Outline for the Opening the Interview

Setting the Stage

Goal: To establish a favorable context for the interview

  • Welcome the patient

  • Know and use the patient's name

  • Introduce and identify yourself

  • Ensure comfort and privacy

Chief Complaint/Setting the Agenda

Goal: To establish the agenda for the interview

  • Obtain list of all issues - avoid detail

    • Chief Complaint

    • Other complaints or symptoms

    • Specific requests (i.e. medication refills)

  • Patient's expectations for this visit

  • Ask the patient "Why now?"

Eliciting the Patient's Story

Goal: To establish a good flow of information

  • Open-ended questions initially

  • Encourage with silence, nonverbal cues, and verbal cues

  • Focus by paraphrasing and summarizing


Goal: To smoothly shift into physician-centered interviewing

  • Summarize interview up to that point

  • Verbalize your intention to make the transition

An Outline for the Rest of the Interview

Prioritize Problems

This should be clear from the transition summary.

Pursue the Most Urgent Problem (History of Present Illness)

  • Move from general to specific

  • Flow from open-ended to closed-ended questions

Pursue Other Problems as Time Permits

Review of Systems

Past Medical History

  • Allergies/Adverse Reactions

  • Medications/Immunizations

  • Major Medical or Psychiatric Problems/Major Surgeries

  • Last Menstrual Period/Pregnancies/Contraception (if female)

  • Smoking/Alcohol/Caffeine/Other Drugs

Other History (as appropriate)

  • Family/Social History

  • Occupational History

  • Sexual History

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