History Taking
Information Covered:
- Investigation of the Chief Complaint
- The Chief Complaint Is a Very Brief Description of the Reason for Summoning EMS to the Scene
- Factors Influencing the Data Collection
- What is the source of the information?
- Patient
- usually the best source for information
- Family
- Friends
- Bystanders
- Public safety personnel
- Medical identification jewelry or other medical information sources
- Patient
- How reliable is the data?
- What is the source of the information?
- History of the Present Illness
- Detailed evaluation of the chief complaint
- Provides a full, clear, chronological account of the signs and symptoms
- Components of a Patient History
- Statistical and Demographic
- Obtain correct dates
- Accurately document all times
- Identifying data
- Age
- Sex
- Race
- Past Medical History (Pertinent to the Medical Event)
- Medical
- Trauma
- Surgical
- Consider medical identification tag
- Current Health Status (Pertinent to the Medical Event)
- Focuses on present state of health
- Environmental conditions
- Individual factors
- Current medications
- Allergies
- Tobacco use
- Alcohol, drugs and related substances
- Diet
- Screening tests
- Immunizations
- Environmental hazards
- Use of safety measures (in and out of the home)
- Family history
- Statistical and Demographic
- Techniques of History Taking
- Setting the Stage
- Environment – personal space
- EMS personnel demeanor and appearance
- Be aware of body language
- Clean, neat, and professional
- Note-taking
- Difficult to remember all details
- Most patients comfortable with note-taking
- Learning About the Present Illness
- Refer to the patient by name
- Refer to the patient by their last name with the proper title
- Mr., Mrs., or Ms.
- if they inform you to address them by their first name, do so
- Avoid the use of unfamiliar or demeaning terms such as “granny” or “honey”
- Refer to the patient by their last name with the proper title
- Refer to the patient by name
- Determine Chief Complaint
- Use a general, open-ended question
- Follow the patient’s lead
- Facilitation
- posture, actions, or words should encourage the patient to say more
- making eye contact or saying phrases such as “go on” or “I’m listening” may help the patient to continue
- Reflection
- repeating the patient’s words encourages additional responses
- typically does not bias the story or interrupt the patient’s train of thought
- Clarification – used to clarify ambiguous statements or words
- Facilitation
- Setting the Stage
- Empathetic responses – use techniques of therapeutic communication to interpret feelings and your response
- Confrontation – some issues or responses may require you to confront patients about their feelings
- Interpretation – goes beyond confrontation, requires you to make an inference
- History of the Present Illness
- Location (where is it?)
- Onset (when did it start?)
- Provocative, palliative, and positioning
- What makes it worse?
- What makes it better?
- What position is the patient comfortable?
- Quality (what is it like?)
- Radiation (does it move anywhere?)
- Severity
- Attempt to quantify the pain
- Utilize the scale, 1-10
- Time
- Duration
- When did it start?
- How long does it last?
- Associated signs and symptoms
- Pertinent negative(s)
- For trauma patients, determine the mechanism of injury
- Assess Past Medical History (Pertinent to the Medical Event)
- Pre-existing medical conditions or surgeries
- Medications
- Allergies
- Family history
- Social history; travel history
- Current Health Status
- Tobacco use
- Use of alcohol, drugs, and other related substances
- Diet
- Standardized Approach to History-Taking
- SAMPLE History
- S = Signs and symptoms
- A = Allergies
- Medication
- Environmental
- M = Medications
- Over the counter (OTC)
- Prescribed
- Vitamins and herbal
- Birth control / erectile dysfunction / Other people’s medications
- SAMPLE History
- Recreational drugs
- P = Past pertinent medical history – relevant information concerning the illness or injury
- L = Last oral intake
- Fluids
- Food
- Other substances
- E = Events leading to the illness or injury
- What was taking place just prior to the illness or injury?
- OPQRST History
- O = Onset – time the signs or symptoms started
- P = Provocative, palliative, and positioning
- What makes it worse?
- What makes it better?
- Positioning
- in what position is the patient found?
- should the patient remain in that position?
- Q = Quality of the discomfort
- Patient’s ability to describe the type of discomfort
- burning
- stabbing
- crushing
- Patient’s ability to describe the type of discomfort
- R = Radiation
- Does the discomfort move in any direction?
- S = Severity
- Pain scale
- T = Time
- Relating to onset, however, more definitive in regards to initial onset in the history
- Taking History on Sensitive Topics
- Alcohol and Drugs
- Physical Abuse or Violence
- Sexual History
- Special Challenges
- Silent patient
- Silence is often uncomfortable
- Be alert for nonverbal clues of distress
- Silence may be the result of the interviewer’s lack of sensitivity
- Overly talkative patients
- Give the patient free reign for the first several minutes
- Summarize frequently
- Patient with multiple symptoms
- Silent patient
- Anxious patient
- Be sensitive to nonverbal clues
- Reassurance
- Angry and hostile patient
- Understand that anger and hostility are natural
- Often the anger is displaced toward the clinician
- Do not get angry in return
- Intoxicated patient
- Be accepting, not challenging
- Do not attempt to have the patient lower their voice or stop cursing; this may aggravate them
- Avoid trapping them in small areas
- Treat with dignity, despite their intoxication
- Crying patient may provide valuable insight
- Depressed patient
- Be alert for signs of depression
- Be willing to listen and be non-judgmental
- Patient with confusing behavior or history
- Patient with limited cognitive abilities
- Do not overlook the ability of these patients to provide you with adequate information
- Be alert for omissions
- EMT-patient language barrier – take every possible step to find a translator
- Patient with hearing problem – if the patient can write, have the patient write down questions and answers on paper
- Patient with visual impairment – be careful to announce presence and provide careful explanations
- Talking with family and friends
- Some patients may not be able to provide you with all information
- Try to find a third party who can help you get the whole story
- Age-Related Variations for Pediatric and Geriatric Assessment and Management
- Pediatric (see Special Patient Population section)
- Geriatric (see Special Patient Population section)
- Obtain eye glasses and hearing aids
- Expect history to take more time
Content Creator: James Stone
CAPCE Course Number: 17-EMTP-F3-8301
NJ Course Number: 141109
Total CE Hours: 1
Level: Basic
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.