As a medical professional, the first and the most vital step towards treating a patient starts with noting the patient's history in totality. Every individual does develop his/ her own style and technique over the years; however, a well done interview will provide you with a better understanding to help better your overall treatment plan as well. It is a given fact that while conversing with your patients' you're supposed to maintain an English speaking fluency as well as ensure that you speak in basic English so that the communication is clear.
This article will teach you the basic art of taking your patient's history down, ensuring you know more to do more for improving the quality of health care.
things to remember when taking patient's history down:
1. Greet the patient:
"Good afternoon, my name is Dr. Duncan."
2. Personal history:
> Patient's name (With correct spelling)
"Please help me out with your first and last name."
> Patient's age, height and weight
"Could you please tell me your age, height, as well as weight?"
> Patient's occupation
"What's your present job profile?"
"How much physical activity is involved in your job?"
3. Patient's chief complaint (CC)
"How can I help you today?"
"What seems to be the problem?"
4. Duration of the CC
"When exactly did this problem start?"
"For how long have you been facing this issue?"
"Have you taken any medicine so far?"
5. Ask for aggravating factors:
"Have you noticed anything that makes this problem worse?"
"Is there anything that helps relieve this issue?"
6. Understand the onset:
"Did this problem arise all of a sudden, or did you notice it as a slow entrant?"
7. Pains associated with the problem:
"Are you facing any pain due to this?"
"Describe the pain to me- Is it burning, constant, throbbing, or sharp?"
"On a scale of 1 to 10, rank the intensity of the pain."
"Any hindrance caused in your day-to-day life due to this issue?"
8. Current and past medical history:
"Are you having any health problems such as diabetes, high blood pressure at present?"
If the answer is yes, ask follow up questions such as:
Since how long? Are you seeing a doctor? What are the medications? Name them? How many doses? When did you last visit your specialist?
9. Family history:
"Do your parents have any health issues? How old are they?"
"Do you have siblings?"
"Do they have any health issues?""Are you married?"
"Is there a family history of high blood pressure, cancer, asthma, or diabetes in your or your partner's family?"
10. Drug history:
"At present are you taking any prescribed medicines such as pills, injections, inhalers?"
"Are you taking any over the counter medicines?"
11. Lifestyle (Social) history:
> "Do you smoke?"
If yes:
"How much do you smoke?"
"At what age did you take up smoking?"
> "Do you drink?"
If yes:
"Do you drink beer, wine or hard drinks?"
"How often do you drink?"
The above mentioned pointers are just a basic amalgamation of all the questions you should ideally ask your patient, before beginning the treatment procedure. Understand the fact that your patient will already be scared, so focus on making him/ her comfortable by striking a light conversation as and when possible.
Whatever you do, ensure to keep a tab on your English communication skills, as it is crucial for a nurse or a doctor to speak in English fluently and seamlessly.
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- By Chander Madan
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