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1. •Thehistoryis only one part of patient assessment
and islikelyto be undertaken in conjunction with
otherinformationgathering techniques

2. •Preparing the environmentThefirst part of any
history-taking process and,indeed, most
interactions with patients ispreparationof the
environment.

3. •Respect for the patient as an individual is
animportantfeature of assessment, and this
includesconsiderationof beliefs and values and the
abilitytoremain non-judgementaland professional

4. Communication
•Good communication skills are
essential.Introducingyourself to the patient is the
first partofthis process.

5. Consent
•Before any healthcare intervention,
includinghistorytaking, informed consent should
begainedfrom the patient.

6. Thehistory-takingprocess
•Once this has been completed, it is besttobegin by
establishing the identity of the patientandhow he
or she would like to be addressed

7. •It is important to use appropriatequestioning
techniques to ensure that nothing ismissedwhen
taking a history from a patient.

8. •Once the patient has completedhisor her ‘story’
move on to clarify and focuswithspecific questions.

9. •Clarification involves recallingbackto the patient
your understanding of thehistory, symptoms and
remarks.

10. •History-taking sequence
• The presenting complaint.
• Past medical history.
• Mental health.
• Medication history.
• Family history.
Social history.
Sexual history.
Occupational history.
Systemic enquiry.
Further information from a third party
Summary.

11. •Calgary Cambridge framework
•Explanationand plannin
•Aidingaccuraterecalland understanding
•Achievinga sharedunderstanding
•Planningthroughshareddecisionmaking
•Closingtheconsultation

12. •start by using anopenquestion, for example: ‘What
is theproblem?’ or ‘Tell me about the problem?

13. •The patient should then beaskedmore specific
details about his or hersymptoms, starting with the
most important first.Itis important to concentrate
on symptoms andnoton diagnosis to ensure that
no information ismissed.

14. •Each symptom should be explored in moredetailfor
clarification because this helps toconstructa more
accurate description of thepatient’sproblems

15. •Onset – Duration – Site and radiation –
Aggravating and relieving features – Associated
symptoms – Fluctuating – Frequency –

16. •Cardinal symptomsGeneralhealth
•Cardiovascular system, Central nervoussystem,
Endocrine, Gastrointestinal system, Genitourinary
system, Men, Musculoskeletal, Respiratorysystem,
Women

17. •Itconsideredthe key points required in taking
acomprehensivehistory from a patient,
includingpreparingthe environment,
communicationskillsand the importance of order

18. •The history-taking interview should be of ahigh
quality and must be accurately recorded