Patients visit their physicians when they have a medical concern or a health complaint bothers them. They come with a hope that the physician would be able to understand their medical problem and provide treatment and care for the same. On the physician’s side it is of utmost importance to understand the patient’s complaints and have effective doctor patient communication, which can be done by taking patient’s medical history.
Medical History Taking
History taking of a patient is an essential part of patient assessment. Patient history includes various aspects of patient’s details, medical concerns and past occurrences. The key points to be considered while taking medical history include,
Concerns and symptoms, which the patient is presently experiencing, the nature, intensity and frequency of symptoms. The way it began, its relation to other complaints, associated complaints and everything the patient wishes to narrate about it. Previous consultations, investigation reports and treatment for the same are assessed.
Previous history of medical conditions related to present complaints or occurrences of other complaints. Existing ailments like heart diseases, diabetes, asthma or hypertension, any history of injuries, surgeries or allergies are noted.
Family history of various ailments, causes of deaths, if any are enquired, to assess patient’s risk factors in some cases.
Medications that the patient is presently taking or has taken in the past. Any drug allergy or intolerance to assess interactions with other medical conditions, foods or drugs.
Diet and Lifestyle
Diet preferences, lifestyle habits, smoking, alcohol their frequency and other details are noted. Sexual preferences, emotional health, impact of the medical complaints on emotional wellbeing and social life are also considered. Occupational issues or problems dealing with everyday activities are taking into account.
In addition to a dialogue with the patient, a thorough clinical examination in a systematic manner is important. Checking the degree of pain, tenderness, swelling, reflexes and assessing the functional abilities gives an idea of the possible concern.
Effective medical history taking – benefits
Effective medical history taking is the art of a physician, which is based on medical sciences. It is said that, ‘a well taken medical history means the case is partly solved.’ A competent physician surely understands the importance of a good and comprehensive case taking, which reveals the smallest details of the patient’s medical history.
Some of the benefits that an effective medical history taking provides are as follows:
When the physician takes a proper clinical history, asks relevant questions, the chances of narrowing down to possible diagnosis is high. With information about past history of the patient, familial tendencies, it promotes better understanding of the case and quick diagnosis can be made.
Ordering relevant investigations
Thorough clinical history enables the physician to order only relevant investigations, when certain symptoms are overlapping and need laboratory confirmation. When the diagnosis is clear and can be made on clinical picture, it will avoid unnecessary investigations, thus saving healthcare resources and reducing costs.
Understanding risk factors
With deeper understanding of patient’s complaints, lifestyle, past medical ailments and familial medical tendencies, the physician can help in risk assessment for the patient. The physician may be able to understand the patient’s health risks, specific risks about certain disorders and guide the patient accordingly.
Preventive health and disease management
Considering patient’s health, relevant complaints and risk factors, physicians can suggest appropriate screening tests, vaccinations, lifestyle modifications or dietary changes and could communicate preventive healthcare measures, if any. In case of live-with-it conditions, guidance regarding rehabilitation therapies and health management to prevent further damage can be planned.
Improved patient health
The combined effect of all the benefits ultimately helps to provide the best quality medical care to the patient, without unnecessary expenses. Timely diagnosis, planned approach to necessary investigations, effective treatment, guidance on preventive health and personal attention help to improve patient health and their overall experience.
Better patient satisfaction
Taking a history involves communication with the patient and sometime even the family members. This helps to develop a rapport, which initiates a positive feeling for the medical team on the part of the patient. The physician takes the opportunity to clarify patient’s queries, address their concerns and counsel the patient as appropriate. Patients are contented to receive physician’s attention and quality time; also the emphasis on preventive health and rehabilitation creates a sense of responsibility and satisfaction and creates a good patient experience in hospitals.
Patient’s medical history taking begins from the time the patients fill complaint form or narrates their complaints to a healthcare professional like nurses, junior doctors or consulting physicians. Hence, it is essential that every healthcare professional is aware of the history taking basics. History taking is an art and healthcare professionals, who master this skill can ensure self-growth and improves health care system.