Chapter 12:
History Taking
History Taking
• Refers to information gathered during a
patient interview
• Provides an account of:
• Medical and social occurrences in a
patient’s life
• Environmental factors that may have a
bearing on the patient’s condition
Components of Patient History
• Date and time • Chief complaint
• Identifying data • Present illness
• Source of referral • Past history
• Source of history • Current health status
• Review of body
systems
Techniques of History Taking
• Setting the Stage
• The environment
• Your demeanor and appearance
• Note taking
Learning about the Present Illness
• Greeting the patient
• Greet by name
• Shake hands
• Avoid the use of unfamiliar or demeaning
terms
• The patient’s comfort
• Be alert to patient comfort levels
• Ask about the patient’s feelings
• Watch for signs of uneasiness
Opening Questions
• Find out why the patient is seeking
medical care or advice
• Use a general, open-ended question
• Follow the patient’s leads
Therapeutic Communication
• Facilitation
• Reflection
• Clarification
• Empathy
• Confrontation
• Interpretation
Chief Complaint
• The one or more symptoms for which
the patient is seeking medical care
• Most chief complaints are
characterized by:
• Pain
• Abnormal function
• A change in the patient's normal state or
• An unusual observation made by the
patient (e.g., heart palpitations)
Chief Complaint
• Be alert to the possibility that a chief
complaint may be misleading or a
problem may be more serious than the
patient's chief complaint
History of Present Illness (HPI)
• Identifies the chief complaint and
provides a full, clear, chronological
account of the symptoms
• A thorough HPI requires skill in:
• Asking appropriate questions related
to chief complaint
• Interpreting patient's response to
those questions
OPQRST
• Onset of problem
• Provocation/palliative
• Quality
• Region/radiation/referral
• Severity
• Time
History of Present Illness (HPI)
• Pertinent positives and negatives
• Pertinent positives - findings verified by the
history or physical examination
• Pertinent negatives - findings not verified
by the history or physical examination
Significant Past Medical History
• General state of health
• Childhood illnesses
• Adult illnesses
• Accidents and injuries
• Surgeries or hospitalizations
• Psychiatric illnesses
Current Health Status
• Allergies
• Medication allergies
• Food allergies
• Environmental allergies
• Look for medical identification devices
Medications
• Ask if the patient takes any medications
regularly and why
• Determine medication compliance
• Ask about nonprescription medications
• Ask about nonprescribed drugs for
recreational purposes
Pertinent Past Medical History
• Medical history
• Family history
Last Oral Intake
• May affect potential airway problems if
patient loses consciousness
• May help determine appropriateness of
surgery
• May help rule out other problems
Last Menstrual Period
• Important for women with abdominal
pain
• Patient’s response should determine the
need to pursue additional questions
regarding:
• Contraceptive use
• Venereal disease
• Urinary tract infections
• Ectopic pregnancy
Last Bowel Movement
• Determine if normal or abnormal for patient
• Obtain related history
• Diarrhea
• Constipation
• Bloody bowel movements
• Discuss abnormal urinary function
• Hematuria
• Urethral discharge
• Pain or burning with urination
• Frequent urination
• Inability to void
Events Before the Emergency
• May be obtained from patient and/or
bystanders
• Attempt to correlate any event with the
beginning or progression of an illness
or injury
Environmental Conditions
• Home conditions
• Occupation
• Travel
• Exposure to contagious diseases
• Military record
• Geographical areas
• Exposure to chemicals
Patient History
• Personal Habits
• Tobacco use
• Alcohol, other drugs, and related substances
• Diet
• Normal daily intake of food and beverages
• Consumption of stimulants
• Special diet
• Appetite
• Tests/immunizations
• Screening tests
• Immunizations
Patient History
• Sleep patterns
• Exercise and leisure activities
• Environmental hazards
• Additional information
• Home situation, spouse, or significant other
• Daily life
• Important experiences
• Religious beliefs
• Patient outlook
Direct Questions
• To gather additional information, direct
questions may be required
• Should not be leading questions
• Ask one question at a time
• Use language that is appropriate
Sensitive Topics
• Alcohol and drugs
• CAGE questionnaire may be a useful tool
when evaluating a patient’s use of alcohol
• CAGE is an acronym for:
• Cutting down
• Annoyance by criticism
• Guilty feeling
• Eye-openers
CAGE Questionnaire
• C
• Have you ever felt the need to Cut down on
your drinking?
• A
• Have you ever felt Annoyed by criticism of
your drinking?
• G
• Have you ever felt Guilty about your drinking?
• E
• Have you ever felt the need for a morning Eye-
opener?
Physical Abuse or Violence
• The battered patient
• Clues about the situation
• Direct questioning is best
• Remember the following key points:
• Nonjudgmental attitude
• Avoid judgmental statements
• Avoid "why" questions
• Supportive attitude
Sexual History
• Questions regarding the patient’s sexual
history may be embarrassing for the
paramedic and patient
• Keep questions "gender neutral"
Review of Systems (ROS)
• General • Gastrointestinal
• Skin • Genitourinary
• Head/Eyes/Ears/ • Musculoskeletal
Nose/Throat • Neurologic
(HEENT) • Hematologic
• Respiratory • Endocrine
• Cardiovascular
• Psychiatric
Special Challenges
• Silence
• Over-talkative patients
• Patients with multiple symptoms
• Anxious patients
False Reassurance
• Providing false reassurance may be
tempting
• Avoid early reassurance or “over
reassurance” until it can be provided
with confidence
Special Challenges
• Anger and hostility
• Intoxication
• Crying
• Depression
• Sexually attractive or seductive patients
• Confusing behavior or histories
• Limited intelligence
Communication Barriers
• Barriers in communication may result
from:
• Social or cultural differences
• Sight, speech, or hearing impairments
• Attempt to find assistance to aid in
communication
Talking with Family and Friends
• Friends and family are often at the scene of an
emergency
• Should be considered a good source of
information
• Are often helpful when the patient cannot provide
all necessary information due to illness or injury
• If not available and additional patient
information is needed, try to locate a third
party who can help supply missing data
