A good history taking is an important first step in treating the patient. Each person will develop their own style and technique, but good interview will likely include the basic elements.
The better you understand your patient, the treatment plan(Physician) will be and the more likely you will be to get good patient compliance.
Two parts of patients interview:
1. Office Setting – it is important because it creates the environment in which you and the patient must interact. It is normal to expect patients to experience some degree of anxiety during an initial interview and that is because you are a complete stranger. HIPAA compliance is a must during patient interview.
2. The Process of Interview – Use an “Open-ended questions”. (Example: Tell me about your problem?) Note: Document Chief complaint, Sign and Symptoms.
Here are the basic elements:
1. Greet the Patient ( Introduce yourself, Identify the patient, Assessment of the patient’s overall appearance and demeanor.
2. Personal History starts by asking ( Age, Occupation, Sex, Height/Weight, Marital/Family Status)
3. Chief complaint (CC) or Presenting complaint (Why is the patient seek care?, What other problems concern the patient has?)
4. History of present illness (Location, radiation , duration, severity of complaint then the timing of onset, Situation(setting) onset, previous similar complaints, Exacerbating and Relieving factors, Associated symptoms and Patient’s explanation of complaint).
5. Past Medical History
a. Systematic questioning regarding previous adult illness such as Neurological/Psychiatric, Eye/Ears/Nose/Throat(EENT), Skin/Hair/Nails, Musculoskeletal, Cardiovascular/Respiratory, Genital-urinary & GI tract.
b. Childhood Illness
c. Surgeries, injuries or hospitalizations
d. OB/GYN (Birth Control, Pregnancies/Births, Menstrual period, Pelvic exams/Pap smear)
e. Psychiatric
f. Immunizations
g. Screening tests
h. Allergies
6. Family history ( Disease history, Parental health and Children’s health)
7. Drug history (Current medication, Prescription and Over -the -counter)
8. Lifestyle (social history)
a. Alcohol
b. Smoking
c. Recreation drug use
d. Sexual lifestyle/orientation
e. Reproductive status
f. Occupational issues
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