History Taking

History Taking

1. The art of history talking

   • The basis of a true history is good communication between doctor and patient.
   • It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks
   • A good history is one which reveals the patient's ideas, concerns and expectations as well as any accompanying diagnosis.

2. Consultation Skills

   • There are many examples of aspects of consulting which may assist history taking for doctors working with patients in all specialties.
     • Setting
       • Take care not to let the computer intrude on the consultation.
       • Good eye contact, shaking hands with the patient and showing an active interest in the patient should help to establish trust and encourage honest and open communication.
     • Listen first and listen second
       • Let the patient tell you the story they have been storing up for you. This can be encouraged by active listening.
       • This implies that the doctor is seen to be interested and attentive by the patient.
       • Also use facial expression, body language and verbal fluency to help understand what is really troubling someone and to suggest other areas in which the history might need to proceed

3. What questions?

   • Open questions
     • Open questions can be used to obtain specific information about a particular symptom as well
   • Questions with options
     • If the information you are after cannot be obtained through open questioning then give the patient some options to indicate what information you need.
   • Leading questions
   • Summarising
     • it's useful to give the patient a run-down of what they've told you as you understand it
   • Sharing understanding
     • It's always a good idea to ask the patient if there's anything they want to ask you at the end of a consultation
   • Conclusion
     • Try to let patients tell you their story freely.
     • When you use questions, try to keep them as open as possible.
     • Use all your senses to 'listen'.
     • Keep an open mind and always ask yourself if you're making assumptions.