HISTORY TAKING skill that must be developed by a doctor and not memorized. tion.htm

CHIEF COMPLAINT Each encounter MUST begin with the chief complaint It is often documented in the pt’s own words It should be concise and describe the symptoms, diagnosis or other reasons for the encounter Example; “I have a urinary tract infection”

The chief complaint may also include duration of time Example; “ I have chest pain” x 3 hours

History of presenting illness (HPI) Is the subjective story given to you by the patient in response to the questions you pose. It is to be preceded by an open-ended question Open ended questions: are questions that forces the patient to begin telling you a story. Open-ended questions cannot be answered with a “yes” or “no” response. Example; “what brings you in today”,

Distracting patients Some patients may need to be redirected back to the basis of their visit in the case of deviation. MUST be done courteously Example: “I am sorry to interrupt, and if we have time, we can come back to that, but can you tell me when you had the chest pain last?”

CLOSE-ENDED QUESTIONS In patients unable to answer an open-ended question. These questions require a yes/no or more specific response. Example; Open-ended: “Describe the chest pain” Response: “I don’t know, it just hurts” Close-ended: “Is it sharp, dull, achy, pressure, squeezing?”

While asking the appropriate questions, physicians must strive to understand exactly what the patient means with their choice of words.

Logical sequence Helps you to think without memorizing cos…… One answer from the patient often leads to the next question Note: your role is to keep the patient on track with exploring his/her chief complaint while also gaining sufficient information to obtain an accurate diagnosis.

example Doctor: “Do you drink alcohol?” Patient: “yes” Doctor: “how often do you drink?” Patient: “every day” Doctor: “ how much do you drink in a day?” Patient: “only one glass of wine a day?”

Components of HPI To prevent physicians from returning to the room several times to ask the questions they forgot the first time, there is a mnemonic (CODIERSMMASSH)

MNEMONICOVERVIEWSPECIFIC QUESTIONS C- ChronologyTime frame showing the sequence of events Have you ever had this before? How has it changed? What was the order of symptoms O- OnsetOccurrenceWhen did current symptoms start? D- Description Duration Describe it Length of time What does it feel like? How long does it last? I- IntensityScaleOn a scale from 1 to 10, how bad is the pain? E- Exacerbating factorsWhat makes it worse? R- Remitting factorsWhat makes it better? S- Symptoms associatedConcurrent findingsFor a cold: Do you have a fever or chills? M- MedicationsName, dose, frequency? M- Medical historyPrevious medical diagnosis?

A- allergiesFood, environmental, drug and what happens? S- Surgical historyWhat? When? S- Social historyTobacco, ETOH, drugs, occupation H- HospitalizationWHAT? WHERE?, WHEN?

For female: ask when the FIRST Day Of Last Menstrual Period (FDLNMP) occurred. Not all histories will have every component of CODIERSMMASSH

REVIEW OF SYSTEM Is an inventory of symptoms related to the body’s systems and documented separately from “CODIERSMMASSH” Review of system mostly answer the question of “ symptoms associated”