History Taking

History Taking

Information Covered:

  1. Investigation of the Chief Complaint
    1. The Chief Complaint Is a Very Brief Description of the Reason for Summoning EMS to the Scene
    2. Factors Influencing the Data Collection
      1. What is the source of the information?
        1. Patient
          1. usually the best source for information
        2. Family
        3. Friends
        4. Bystanders
        5. Public safety personnel
        6. Medical identification jewelry or other medical information sources
      2. How reliable is the data?
    3. History of the Present Illness
      1. Detailed evaluation of the chief complaint
      2. Provides a full, clear, chronological account of the signs and symptoms
  2. Components of a Patient History
    1. Statistical and Demographic
      1. Obtain correct dates
      2. Accurately document all times
      3. Identifying data
        1. Age
        2. Sex
        3. Race
    2. Past Medical History (Pertinent to the Medical Event)
      1. Medical
      2. Trauma
      3. Surgical
      4. Consider medical identification tag
    3. Current Health Status (Pertinent to the Medical Event)
      1. Focuses on present state of health
      2. Environmental conditions
      3. Individual factors
        1. Current medications
        2. Allergies
        3. Tobacco use
        4. Alcohol, drugs and related substances
        5. Diet
        6. Screening tests
        7. Immunizations
        8. Environmental hazards
        9. Use of safety measures (in and out of the home)
        10. Family history
  3. Techniques of History Taking
    1. Setting the Stage
      1. Environment –  personal space
      2. EMS personnel demeanor and appearance
        1. Be aware of body language
        2. Clean, neat, and professional
      3. Note-taking
        1. Difficult to remember all details
        2. Most patients comfortable with note-taking
    2. Learning About the Present Illness
      1. Refer to the patient by name
        1. Refer to the patient by their last name with the proper title
          1. Mr., Mrs., or Ms.
          2. if they inform you to address them by their first name, do so
        2. Avoid the use of unfamiliar or demeaning terms such as “granny” or “honey”
    3. Determine Chief Complaint
      1. Use a general, open-ended question
      2. Follow the patient’s lead
        1. Facilitation
          1. posture, actions, or words should encourage the patient to say more
          2. making eye contact or saying phrases such as “go on” or “I’m listening” may help the patient to continue
        2. Reflection
          1. repeating the patient’s words encourages additional responses
          2. typically does not bias the story or interrupt the patient’s train of thought
        3. Clarification – used to clarify ambiguous statements or words
  4. Empathetic responses – use techniques of therapeutic communication to interpret feelings and your response
  5. Confrontation – some issues or responses may require you to confront patients about their feelings
  6. Interpretation – goes beyond confrontation, requires you to make an inference
  7. History of the Present Illness
    1. Location (where is it?)
    2. Onset (when did it start?)
    3. Provocative, palliative, and positioning
      1. What makes it worse?
      2. What makes it better?
      3. What position is the patient comfortable?
    4. Quality (what is it like?)
    5. Radiation (does it move anywhere?)
    6. Severity
      1. Attempt to quantify the pain
      2. Utilize the scale, 1-10
    7. Time
      1. Duration
      2. When did it start?
      3. How long does it last?
    8. Associated signs and symptoms
    9. Pertinent negative(s)
    10. For trauma patients, determine the mechanism of injury
  8. Assess Past Medical History (Pertinent to the Medical Event)
    1. Pre-existing medical conditions or surgeries
    2. Medications
    3. Allergies
    4. Family history
    5. Social history; travel history
  9. Current Health Status
    1. Tobacco use
    2. Use of alcohol, drugs, and other related substances
    3. Diet
  10. Standardized Approach to History-Taking
    1. SAMPLE History
      1. S = Signs and symptoms
      2. A = Allergies
        1. Medication
        2. Environmental
      3. M = Medications
        1. Over the counter (OTC)
        2. Prescribed
        3. Vitamins and herbal
        4. Birth control / erectile dysfunction / Other people’s medications
  11. Recreational drugs
  12. P = Past pertinent medical history – relevant information concerning the illness or injury
  13. L = Last oral intake
    1. Fluids
    2. Food
    3. Other substances
  14. E = Events leading to the illness or injury
    1. What was taking place just prior to the illness or injury?
  15. OPQRST History
    1. O = Onset – time the signs or symptoms started
    2. P = Provocative, palliative, and positioning
      1. What makes it worse?
      2. What makes it better?
      3. Positioning
        1. in what position is the patient found?
        2. should the patient remain in that position?
    3. Q = Quality of the discomfort
      1. Patient’s ability to describe the type of discomfort
        1. burning
        2. stabbing
        3. crushing
    4. R = Radiation
      1. Does the discomfort move in any direction?
    5. S = Severity
      1. Pain scale
    6. T = Time
      1. Relating to onset, however, more definitive in regards to initial onset in the history
  16. Taking History on Sensitive Topics
    1. Alcohol and Drugs
    2. Physical Abuse or Violence
    3. Sexual History
    4. Special Challenges
      1. Silent patient
        1. Silence is often uncomfortable
        2. Be alert for nonverbal clues of distress
        3. Silence may be the result of the interviewer’s lack of sensitivity
      2. Overly talkative patients
        1. Give the patient free reign for the first several minutes
        2. Summarize frequently
      3. Patient with multiple symptoms
  17. Anxious patient
    1. Be sensitive to nonverbal clues
    2. Reassurance
  18. Angry and  hostile patient
    1. Understand that anger and hostility are natural
    2. Often the anger is displaced toward the clinician
    3. Do not get angry in return
  19. Intoxicated patient
    1. Be accepting, not challenging
    2. Do not attempt to have the patient lower their voice or stop cursing; this may aggravate them
    3. Avoid trapping them in small areas
    4. Treat with dignity, despite their intoxication
  20. Crying patient may provide valuable insight
  21. Depressed patient
    1. Be alert for signs of depression
    2. Be willing to listen and be non-judgmental
  22. Patient with confusing behavior or history
  23. Patient with limited cognitive abilities
    1. Do not overlook the ability of these patients to provide you with adequate information
    2. Be alert for omissions
  24. EMT-patient language barrier – take every possible step to find a translator
  25. Patient with hearing problem – if the patient can write, have the patient write down questions and answers on paper
  26. Patient with visual impairment – be careful to announce presence and provide careful explanations
  27. Talking with family and friends
    1. Some patients may not be able to provide you with all information
    2. Try to find a third party who can help you get the whole story
  28. Age-Related Variations for Pediatric and Geriatric Assessment and Management
    1. Pediatric (see Special Patient Population section)
    2. Geriatric (see Special Patient Population section)
      1. Obtain eye glasses and hearing aids
      2. Expect history to take more time

 

Content Creator: James Stone

CAPCE Course Number: 17-EMTP-F3-8301

Total CE Hours: 0.75

Level: Basic

EMT-CE uses the NEMSES guidelines as the foundation for every course outline.