A guide to taking a patients

Depending on the PC it may also be pertinent to find out whether the patient drives, e. They tend to lead the patient down an avenue that is framed by your own assumptions.

History taking in nursing pdf

Remember that speech is not the only means of communicating, especially where someone has a poor command of the language in which you are taking the history, or has hearing impairment. This may be with a child or an adult with impaired mental state. Sticking with chest pain as an example you should ask: Site: Where exactly is the pain? A good history is one which reveals the patient's ideas, concerns and expectations as well as any accompanying diagnosis. At this point it is a good idea to find out if the patient has any allergies. Step 05 - Drug History DH Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. Indeed 'questions' may need to be avoided, as they limit the patient to 'answers'. Conclusion Try to let patients tell you their story freely. Step 02 - Presenting Complaint PC This is what the patient tells you is wrong, for example: chest pain. The basis of a true history is good communication between doctor and patient. They tend to lead the patient down an avenue that is framed by your own assumptions. To obtain a true, representative account of what is troubling a patient and how it has evolved over time, is not an easy task. Generally, it helps to be warm and welcoming so as to put the patient at ease. Depending on the PC it may also be pertinent to find out whether the patient drives, e. It can facilitate establishing rapport with patients by, for example, allowing for good eye contact, enabling easy access to computers or notes and avoiding 'distance' between the doctor and patient.

Take care with the opening greeting, as this can set the scene for what follows. The basis of a true history is good communication between doctor and patient.

A consultation can allow a patient to unburden himself or herself. This can be difficult when there is useful information available on a screen. Generally, it helps to be warm and welcoming so as to put the patient at ease.

For instance, a male patient presents with episodic chest pain. Setting The layout of the consulting room can assist good consulting. Remember that speech is not the only means of communicating, especially where someone has a poor command of the language in which you are taking the history, or has hearing impairment.

Make full use of communication aids such as translators, sign-language interpreters, picture boards, and drawings done by the patient showing where the pain is, when this is a more appropriate form of discourse. Sticking with chest pain as an example you should ask: Site: Where exactly is the pain?

The above example involves the CVS so you would focus on the others.

importance of patient history taking
Rated 8/10 based on 100 review
Download
Guide to Taking Patient's History Admission/Application Essay