Documentation

History taking and communication are essential skills for physicians, and they have evolved over time to reflect advances in medical knowledge and technology. Today, physicians are expected to communicate with patients in a respectful, informative, and compassionate way.

Learning Objectives

• Understand the importance of history taking and
• Understand the general ethics of history taking.
• Identify the challenges or dangers of hapzard of history taking.
• Understand the benefits/impacts of a systematic approach to history taking.
• Understand the sections of the structured approach to history taking

Historical perspective of history taking

Before the systematic approach to patient clerking was adopted, history taking was often haphazard and inconsistent. Clinicians would ask patients questions based on their own experience and intuition, and they may not have asked all of the relevant questions. This could lead to incomplete or inaccurate information being collected, which could make it difficult to diagnose and treat diseases accurately.

Here are some of the specific challenges of history taking before the systematic approach was adopted:

• Incomplete information: Clinicians may not have asked all of the relevant questions, or they may not have asked the questions in a way that elicited accurate information. This could lead to incomplete or inaccurate information being collected, which could make it difficult to diagnose and treat diseases accurately.
• Inconsistency: Clinicians may have asked different patients different questions, or they may have asked the same questions in different ways. This could lead to inconsistent information being collected, which could make it difficult to compare patients and to track changes in their conditions over time.
• Bias: Clinicians may have been biased in their questioning, leading them to focus on certain aspects of the patient’s history and to ignore others. This could lead to inaccurate or incomplete information being collected, which could make it difficult to diagnose and treat diseases accurately.

The systematic approach to history taking was developed to address these challenges. It provides a framework for clinicians to collect information from patients in a comprehensive and consistent manner. This helps to ensure that all of the relevant information is collected, and that it is collected in a way that is unbiased to form to form a diagnosis and develop a treatment plan.

In the 18th century, the Scottish physician William Cullen known for the contribution to medical education used a systematic approach to history taking. The systematic approach had four(4) parts:

1. Chief complaint: The patient’s main reason for seeking medical care.
2. History of present illness: A detailed account of the patient’s current symptoms, including the onset, duration, and severity of the symptoms.
3. Past medical history: The patient’s past medical problems, surgeries, and medications.
4. Social history: The patient’s lifestyle, including their occupation, hobbies, and travel history.

This systematic approach to history taking is still used today, with some modifications. The systematic approach to history taking and communication has been shown to reduce the rate of surgical complications. A number of studies have shown that using a systematic approach to history taking and communication can improve patient outcomes, including reducing the rate of surgical complications. For example, a study published in the Journal of Surgical Research found that using a checklist-based approach to history taking and communication reduced the rate of surgical complications by 20%. Another study, published in the journal Annals of Surgery, found that using a team-based approach to history taking and communication reduced the rate of surgical complications by 15%.

 

General ethics of communicating with patients

When communicating with patients to extract the history, clinicians should communicate with patients in a way that is respectful, informative, and compassionate. Physicians should listen carefully to patients’ concerns and answer their questions in a clear and concise way. Physicians should also involve patients in decision-making about their care.

Taking a patient’s history is a skill that needs regular practice, good rapport, and adaptation based on the information gathered. If clinicians are not skilled enough, they may make wrong diagnoses and delay proper treatments. A systematic and unhurried approach is essential for history taking. The environment, attention, and order of questions influence the quality of the history taking and the patient’s cooperation. The patient should be encouraged to narrate their stories while the clinician listens attentively. Notes should be taken after the patient finishes talking, not during. The relatives and friends can speak after the patient, and then the clinician can summarize to confirm everyone’s understanding. The questions should aim to find clues, both clear and subtle, to distinguish between different possible diagnosis. Each clinical situation may need a specific pattern of questioning that is learned by experience and constant practice. The patient should not be interrupted or prompted by the clinician. The patient should use their own words and the clinician should record them accurately

 

 

Benefits of a systematic approach to history taking:

• Improved accuracy and completeness of history taking, leading to more accurate diagnosis and treatment.
• Better ability to identify the root cause of illness, leading to more effective treatment and improved patient outcomes.
• Reduced risk of misdiagnosis and mistreatment.
• Improved patient satisfaction, confidence, and trust in the healthcare system.
• Reduced friction and litigation.
• Reduced rate of surgical complications.
• Provides efficient method of extracting information ( Saves time)

How a systematic approach to history taking and communication reduces the rate of surgical complications:

• Identifying and addressing risk factors before surgery.
• Ensuring that the patient understands the risks and benefits of surgery, as well as the preoperative instructions.
• Improving teamwork and communication among the surgical team.

Contemporary Recommendations on the Regions/Sections

Introduction: Introducing yourself, confirming the patient’s identity, obtaining permission, and positioning yourself appropriately.

Biodata: Name, Age, Sex, Occupation, Religion, Address, Marital Status

Chief complaint: The chief complaint is the patient’s main reason for seeking medical care. It should be stated in the patient’s own words, and it should be clear and concise.

History of present illness: The history of present illness is a detailed account of the patient’s current symptoms. It should include the following. Asking about the history of presenting complaint, using a structured approach such as PQRST for pain

• • Onset: When did the symptoms start?
  • Duration: How long have the symptoms lasted?
  • Severity: How severe are the symptoms?
  • Quality: What do the symptoms feel like?
  • Location: Where are the symptoms located?
  • Aggravating factors: What makes the symptoms worse?
  • Relieving factors: What makes the symptoms better?

Asking about the presenting complaint, using open questions and eliciting the patient’s ideas, concerns, and expectations

Past medical history: The past medical history includes all of the patient’s past medical problems, surgeries, and medications. It is important to inquire about any chronic medical conditions, such as diabetes, hypertension, or heart disease. It is also important to inquire about any recent illnesses or hospitalizations. Asking about the past medical history, including any previous illnesses, hospitalizations, surgeries, medications, allergies, and preventive health measures3.

 

Social history: The social history includes the patient’s lifestyle, including their occupation, hobbies, and travel history. It is also important to inquire about the patient’s alcohol and tobacco use including Marriage and Nuclear family finding.

Family History:  Extended family, Asking about specific risk factors related to the presenting complaint, such as smoking, cholesterol, diabetes, hypertension, family history of ischemic heart disease for chest pain. Asking about the social, family, and occupational history, including any relevant factors that may affect the patient’s health or well-being.

 

Review of other systems: Asking about the review of systems, covering all major organ systems to identify any other symptoms or signs that may be related or unrelated to the presenting complaint

Physical examination: Performing a physical examination, following a systematic approach such as inspection, palpation, percussion, auscultation for each system

• Inspection: Inspection is the visual examination of the patient. It is important to inspect the patient’s general appearance, skin, hair, nails, eyes, ears, nose, throat, neck, chest, abdomen, back, extremities, and neurological status.
• Palpation: Palpation is the examination of the patient by touch. It is important to palpate the patient’s skin, lymph nodes, thyroid gland, abdomen, and extremities.
• Percussion: Percussion is the examination of the patient by tapping on the body. It is important to percuss the patient’s chest and abdomen.
• Auscultation: Auscultation is the examination of the patient by listening to the body. It is important to auscultate the patient’s heart, lungs, and abdomen.

Documentation

It is important to document the history taking and physical examination findings in a clear and concise manner. Documenting the findings in the patient’s notes, using clear headings, symbols, diagrams, and shorthand to save time and space. The clinician should then formulate a working diagnosis, differential diagnosis, and care plan based on the history and examination.  The documentation should be in a structured pattern just as the history was extracted