History Taking

History taking is key to helping guide our understanding of the needs of the service user. If you gain a solid history it will help lead to thorough patient assessment/review of systems which in turn will lead to differential diagnosis and also allow for appropriate intervention and selection of appropriate care pathway.

It all starts with a history.

Check out some of the useful tools below:

History taking starts with us talking to the patient about what has lead to our attendance today. It starts with the most recent and relevant point in time, and we need to go further back in time to unravel the history. We can do this by asking questions on top of the answers the patient provides to probe further.

What happens if I get stuck?

Bring it back and ask the easy questions to allow you time to gather thoughts. Using a simple mnemonic like SAMPLE can unlock further history and also prompt you on other questions to ask.

S - Signs and Symptoms

A - Allergies

M - Medications - Prescribed/Over the counter/Recreational/Holistic

P - Past medical history including chronic and acute conditions. Previous surgeries etc.

L - Last oral and medication intake (own analgesia or other meds prior to your arrival)

E - Events leading up to

History of presenting complaint (hxpc)

This is where we build our timeline of events, trying and keep it chronological starting with what the has brought the patient to needing us today, and then work backwards to a relevant point in time to uncover further history.

Consider any previous investigations, admissions, discharges, recent surgery or other treatment.

Liaise with relatives, carers, friends and other health care professionals. Use historic care records to help inform.

Other considerations that will help gain a holistic understanding of your patient will also be their:

Past Medical history

Medication history

Social history

Other helpful mnemonics that are explored further within patient assessment are SOCRATES/OPQRST which are useful for assessing pain, however can also be incorporated into your history.