HISTORY TAKING steps made simple123.pptx

Made simple

1. BY ABDULRAHMAN BELEWA(CHO) HISTORY TAKING

2. What is history taking? It is a process by which information is taken by a Doctor, physician or CHO by asking the patient specific questions with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.

3. Important of history taking Obtaining an accurate history is the first critical step in determining the etiology of a patient illness Diagnosis in medicine is based on Clinical history Physical examination Investigations A large percentage of the time (70%) you will actually be able to make a diagnosis based on good history alone

4. How to take history? The basis of true history is good communication between doctor/CHO and patient It takes practice, patient, understanding and concentration. “Always listen to the patient they might be telling you the diagnosis”

5. General approach Introduce yourself. Note – never forget patient name Create patient appropriately in a friendly relaxed way. Confidentiality and respect patient privacy Try to see things from the patient point of view. Understand patient underneath mental status, anxiety, irritation or depression. always exhibit natural position Listening questioning : simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.

6. Approach to history taking Your look is important correct dressing Wrong dressing

7. Approach to history taking Introduce yourself and create a rapport

8. Approach to history taking Be alert and pay full attention to patient

9. COMPONET OF HISTORY TAKING Patient bio data Chief complaint History of the patient illness Past medical history Family history Social history System Review