History Taking for Health Professionals, Nurses

Detailed history taking notes for health professionals and nurses

1. History Taking Prepared by: P ooja K oirala Lecturer NMCTH

2. Component of history taking Biological information / patient identification data: Name Age Sex Education Marital status Occupation Religion Provisional diagnosis Ward Bed number Inpatient number (IP no.) Attending doctor Source of information Date of admission (DOA) Date of discharge

3. Chief complaint It is the main reason for pushing or coming to hospital or to seek for visiting a physician or hospital Patient can have a single symptom or more than one symptoms / complaints e.g. chest pain, shortness of breath, ankle swelling etc. The patient describes the problem in their own words It should be recorded in patient’s own words in a chronological order

4. Chief complaint cont… Nurses questions the patient in following ways: What is troubling you? Describe the reason you came to the hospital or clinic today? What brings you here?

5. Chief complaint cont… It should be short / specific in one clear sentence. It typically follows the format as: Complaints × duration for which the problem has been bothering the client. Example : C/O (complaining of) back pain since (×) 5 days Diarrhea × 3 days Vomiting × 1 day

6. History of present illness It is the elaborative form of the chief complaints which should be chronological account of the major problems for which the patient is seeking medical care. It should include the onset of problem (when did the problem started?), the setting in which it developed, its manifestations and any treatments. It is necessary to collect the information regarding present illness to strengthen the description of the chief complaint and to clarify its relationship to other symptoms or problem that may be a clue to future diagnosis.

7. Guidelines for assessment of present health problems Symptom analysis O: onset of disease or symptoms: it means the time of starting of the symptom in the body P: proactive or palliative : it means what are the causes of the symptoms? What makes it better or worse? First occurrence: what were you doing when first experienced or noticed the symptoms? Recurrence: what seems to trigger the problem?

8. Q: quality or quantity : it means how the symptom feels, looks or sounds. How much of it are you experiencing now? Quality: how do you describe the symptom and how it feels, looks or sounds? Quantity: how much are you experiencing now so that it prevents you from performing activities? Is it more or less than you experience at any other time?

9. Regions, radiations, reliving or aggravating factors : it means where the symptom is located. Does it spread? Region: where does the symptom occur? Radiation: in the case of pain, does it travel another part of your body? Reliving or aggravating factors: any activities or position

10. S: Severity : it means how the symptom rate is on a severity scale of 1 – 10, with 10 being the most extreme. Severity: how bad is the symptom rate is on a severity scale of 1 – 10, with 10 being the most extreme Course: does the symptom seem to be getting worse or staying about the same?

11. Timing: it means mode (form) of onset (abrupt or gradual), progressing (continuous or intermittent). If intermittent ask frequency / nature). How often does it occur . Onset: on what date did the symptom first occur? What time did it begin? Type of onset: how did the symptom start: suddenly or gradually ? Duration: how long does an episode of the symptoms last?

12. Frequency: how often do you experience the symptom – hourly? Daily? Weekly? Monthly? When do you usually experience it: during the day? Treatment received or (and outcome):

13. A: are there any associated symptoms ? List in a clear chronological order, details of the problems or problems for while the patient is seeking care. For example: When and where did the problem begin ? What kinds of symptoms did the patient experience? Has the patient taken any treatment for the problem

14. What kinds of symptoms did the patient experience? Has the patient taken any treatment for the problem? Has the treatment had any effect on the patient or has treatment not improved or altered patient ‘s condition? Ask the patient if the problem has affected the patient’s lifestyle

15. HOPI for fluids (diarrhea, cough, vaginal fluids) A: Amount B: Blood or other thing C: Color C: Consistency C: Content D: Duration O: Odor

16. Sample According to the mother, the child was active and playful 2 days back, then she developed 8-9 episodes of vomiting, which initially contained the ingested food material (milk) and later turned greenish and watery. It was about 2 teaspoon full in each episode, foul smelling and non-projectile. After around 6 hours, the child developed diarrhea, 10-12 episodes/day, watery with mucoid content, was foul smelling but did not contain blood in the stool. The child cries while passing the stool but not during micturition .

17. Sample cont… There is also history of fever associated with diarrhea which was mild, continuous and not associated with rash and abnormal body movement. There is no loss of appetite, drinks vigorously. Mother gives history of infrequent micturition compared to previous times. No cough, no shortness of breath. No loss of consciousness or avoidance of bright light.

18. 2. Past health history A comprehensive survey of a patient‘s past history provides the information about patient’s major health problems. Similarly, it also gives insight about the health status of the patient up until now. Ask the patient about the Past medical history: Past surgical history

19. Past medical history About past hospitalization and reason of hospitalization Childhood illness: measles, malnutrition, mumps, whooping cough, chicken pox, TB etc Immunization: complete / incomplete Adult illness / previous illness: such as IHD (Ischemic Heart Disease), DM, asthma, TB Medications used: Allergic disorders: any allergic reaction to foods, drugs and others

20. Past surgical history Ask the following: Any type of the surgery in the past e.g. ask time /place / what type of operation etc. Injuries, trauma, accidents e.g. ask time/ place/ what type of injuries and trauma etc Blood transfusion etc

21. Family history It includes the health history as well as their present state of health of the 3 generations in order to identify the risk factors of certain diseases. If death has occurred, then the cause of death is also assessed. One has to determine if certain common diseases run in the family i.e. does a familial pattern exist? In this part of the history, you have to determine the age and health of the parent's parent, grand parents, siblings, spouse and children etc

22. Family history cont… Use written statement and diagram to record the family history Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders

23. Personal history Here the information about the patient’s lifestyle, occupation and habits are obtained. Personal habit : the amount, frequency and duration of substance use (tobacco, alcohol, coffee, cola, tea and illegal or recreational drugs) are obtained Diet : description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnic food patterns, and allergies

24. Sleep patterns : usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties Recreation/hobbies : exercise activity and tolerance, hobbies and other interests, and vacations Questions include: What do you do for recreation, relaxation etc? What kind of job does the patient have? Any job related exposures are present?

25. Personal habits : alcohol / tea/ coffee intake, how much? Any history of vomiting, diarrhea? Smoking cigarettes/ using recreational drugs like marijuana, cocaine, amphetamines etc Ever used IV drugs? Has ever swapped needles? Ever been exposed to any infectious or sexually transmitted diseases?

26. Menstrual history Information about last menstrual period (LMP) Regularity, duration, any contraceptive measures taken, number of living children, still birth, infertility etc.

27. Social history It includes the information about Ethnicity Language spoken Educational status Occupation (type of job) Housing (owning or renting shelter) Type of family Family relationship / friendship Adequacy of income Home and neighborhood conditions

28. Environmental history It includes the information about: Source of drinking water Sanitation status at home and surrounding: type of drainage system, type of toilet, kitchen style, type of fuel used in cooking etc

29. Travel history Traveling increases the risk of unusual or tropical diseases For e.g.: malaria, kalazar , etc

30. Psychological data Major stressors experienced and the client’s perception of them Usual coping pattern for a serious problem or a high level of stress

31. Communication style: ability to verbalize appropriate emotion nonverbal communication—such as eye movements, gestures, use of touch, and posture interactions with support persons and the congruence of nonverbal behavior and verbal expression

32. Review of system

33. Procedure of history taking

34. Articles required for history taking Patients chart Pen / pencil

35. Techniques Be dressed neatly and in a culturally acceptable way for the interview Establish rapport with the patient: greet the patient warmly create a friendly and congenial atmosphere make him / her feel secure and free to talk

36. Techniques cont… Introduce yourself in a friendly manner Maintain privacy. Room should be quiet Arrange the seating in such a way that both the patient and nurse are seated at the same level facing each other Show respect to the patient and his ideas. Call the patient as per the social system like dai , vai , buwa , ama

37. Techniques cont… Explain the purpose of the interview to the patient. Indicate the approximate amount of time required for the interview Observe the patient’s non verbal cues such as anger, guilt, frustration, anxiety etc. when she / he is talking

38. Techniques cont… Make conversation at the level of the patient’s understanding Be an attentive listener Maintain eye contact to make the patient feel that you are listening to him / her Do not interrupt him / her in between unless he / she is moving of the point

39. Techniques cont… Use the history taking format to collect the information. Make notes in short sentences and make them brief as possible Keep the data obtained in the interview confidential and share it with the appropriate health team members only

40. Any questions???

41. Thank you