11 Tips for Taking a Patient History

A comprehensive medical history is vital for an accurate diagnosis, developing personalized treatment plans, and establishing a good rapport with your patients. On today’s Osmosis blog, let’s take note of some helpful tips for recording a high-quality medical history.

Taking a comprehensive and complete medical history is one of the most important skills you’ll learn as a medical student and junior doctor. A good history, paired with a proper clinical examination, can be the key to diagnosing exactly what’s happening with a patient. It can help uncover relevant insights and assist in making well-informed decisions about care. Delving into past medical conditions, family history, lifestyle factors, and existing symptoms enables providers to identify risk factors, diagnose conditions accurately, and develop personalized treatment plans. Taking the time to learn about your patients helps establish rapport and trust by showing them you value what they say and are experiencing.

Preparation and Environment

Before you step into the exam room, prepare yourself. Make sure you have a pen and paper or that you’ve opened their electronic record to accurately record what they tell you. Take the time to read any patient’s notes and look at any test results or imaging. Turn your phone to vibrate or silent, and try to minimize the chance of unnecessary interruptions while you’re meeting. If you’re likely to receive calls during the interview, explain that to them in advance. Your patients should feel that you’re giving them your full attention.

First impressions count no matter what anyone says, so do all you can to make a good one. Introduce yourself and explain your position (medical student, resident, attending, etc.). Ask how they’d like to be addressed. Some people are happy with first names, while others prefer a more formal approach.

A lot of the time, circumstances dictate the environment. For example, don’t assume that being in a treatment room excludes the need to be aware of the environment. Take the time to make sure your patient is comfortable. Ask if they’d like an extra blanket or pillow. Sit close enough so that you can easily hear each other. Make sure that you’re comfortable as well.

Establish Effective Communication

Never underestimate how effective a smile can be in reassuring someone. Many patients are nervous and worried. Taking a few seconds to reassure them before getting into the interview will help put them at ease.

Be clear about why you are there, tell them what you’ll ask them, and why it’s important. Explain that you want to hear what’s been going on with their health in their own words. Confirm that they understand what you’ve told them, and ask them whether they have any questions for you before you begin your exam. Keep your language concise and simple without medical jargon. Emphasize that if they don’t understand anything throughout the interview, make sure they’re empowered to speak up and ask you about it.

Asking someone to tell you a little about themselves is often a great way to start. It might reveal some interesting work experiences or hobbies that you have in common, which will help build rapport. A person’s social history often provides invaluable information when building a picture of the patient, so don’t skip over it. Take the time to learn who they are as a person.

Components of a Good Medical History

By the time you’re treating real patients, you’ll be more than familiar with the components of a good medical history:

Patient Identification and Demographics
Chief Complaint and Presenting Symptoms
Past Medical History (PMH)
Family History (FH)
Social History (SH) and Lifestyle Factors
Medications and Allergies
Review of Systems (ROS)

While all of these elements are important, don’t feel like you have to stick to this exact structure. Let each person tell their story. Sometimes, it’s more natural to change the structure so that you hear the story in their own words.

Use Open-Ended Questions and Follow-ups

Always start with open-ended questions. The idea is to hear what people are experiencing in their own words. Try to listen and hold your questions until they’ve finished sharing their story. When there’s a factor in the story you’d like to learn more about, make a note and come back to it once the patient has finished sharing.

For example, follow up with questions like. “You said before that you wake up with shortness of breath. Tell me more about that: Does it depend on your sleeping position? How long does it last?” Give them the opportunity to paint the broad picture, then go back and fill in the details. Consciously work to avoid asking leading questions or questions that suggest an answer or are biased toward a particular response.

Sensitivity to Individual Patient Culture and Identity

People come from a variety of cultural backgrounds; clinicians must be sensitive to that throughout an interview. Respect your patient’s values and beliefs. Keep in mind that interactions that are acceptable for one person aren’t necessarily going to work for another. And most importantly, note that caregivers and clinicians are responsible for learning how to relate to patients in ways that help them feel seen, heard, and accepted as part of their care.

These conversations can be especially challenging when there are specific medical questions that you need to explore that may be at odds with your patient’s identity or beliefs. The best way to address sensitive issues is to be direct with kindness. Explain that it’s essential that you ask them about a sensitive topic because knowing their answer is integral to understanding who they are and how to manage their care.

Addressing Health Literacy

Everyone has varying degrees of health literacy, so don’t make the mistake of assuming patients understand what you’re telling them. Make sure your word choices are appropriate for both the age and cognitive ability of each individual. Wherever possible, use plain terminology (e.g., “heart attack” rather than “myocardial infarction“) and avoid the use of medical jargon or terms. Encourage patients to ask questions if they’re unsure of what you mean or need clarification. Make use of visual aids and diagrams to explain medical concepts. Ask them to reflect or repeat what they’ve heard you say to confirm they understand what you’ve said to them.

Pay Attention to Non-Verbal Cues

While interpersonal communication skills don’t come naturally to every clinician or caregiver, they’re important to actively learn and apply in practice with your patients.

There are times when what someone doesn’t say can be as, if not more significant than what they do say. Give your patient your full attention. Make eye contact and consciously observe their facial expressions and mannerisms. Look for non-verbal cues (e.g., restlessness or eye contact avoidance); they often provide valuable insights into what is going on in their lives.

It’s always essential to note if the non-verbal cues are at odds with what they’re saying. If you observe that their body language seems to be saying something else, don’t put them on the spot. Instead, add it to the collection of information you’re learning about them, and maybe, if the time is right at a later date, explore it further.

When people are telling you their story, it can be an emotional journey for them. Prepare yourself for this, as it’s important for you to respond appropriately. Also, keep in mind that empathy differs from sympathy; both terms relate to care and concern for others and a desire for their well-being. However, empathy is relating to their feelings and experiences, while sympathy is feeling for their situation (e.g., pity).

Recognizing Red Flags and Critical Symptoms

There are times when a patient may disclose what’s known as a red flag or a critical symptom. Frequently, they may not come straight out and say it but discuss it in their own words. Pay close attention to their story, and if you believe they’re raising a critical symptom, explore it further. Because if they raise an issue that’s considered a red flag, it’s vital that you act decisively and appropriately. Which typically means seeking immediate medical intervention or promptly referring a high-risk patient to a specialist. Document precisely what they’ve said when seeking an intervention or urgent referral.

Most importantly, if you’re unsure, don’t just document it in the notes. Take the next step and seek the advice of your supervisor. It could save a life!

Documentation and Record-Keeping

It’s vital that you document all your interactions with your patients and keep a clear record of what they’ve told you. Use headings and organize your notes so that other health professionals can easily scan them and see the pertinent details. One popular technique is known as SOAP, which organizes your notes as follows:

Subjective findings

Information that the patient has told you. This section can be organized into sub-headings, such as presenting a complaint, family history, etc.

Objective findings

Includes your observations and the results of any clinical examination, lab results, or imaging.

Assessment

Where to put it all together! Gather your thoughts and make an assessment of what you think is happening for the patient.

Plan

Where you write what you plan to do next, and may include any tests you consider necessary, social interventions, further assessments, and so on.

Following the SOAP format makes it easy for other staff members to see what’s been done and what else is necessary to diagnose and treat the patient.

Involve Patients in the Process

Never be afraid to ask a patient what they think is going on! They know their bodies better than anyone and can provide invaluable insights you may not even consider. In addition, it helps patients feel they’re being heard, treated with respect, and that their input is valuable. Remember to discuss any decisions with them and ensure they’re part of the decision-making process.

Continuous Learning and Improvement

Practice taking patient histories whenever the opportunity arises. Not only does it help you improve your clinical skills, it helps to make you feel more comfortable with the process.

Don’t be afraid to take the lead on rounds when called upon. Your colleagues can help by critiquing your performance and providing ideas on how you might improve certain aspects. Watching your colleagues can also help you discover different ways of doing things that might be more natural.

It’s often useful after you’ve completed a patient history to spend five minutes talking with a peer or supervisor to evaluate your performance and consider what aspects you could have handled better or differently.

Conclusion

Being able to take a good patient history is one of the most valuable skills in medicine. It establishes the groundwork when determining what tests or procedures might be necessary and is often instrumental in the final diagnosis. The process of taking a mecial history also reiterates to the patient that they matter and that what they have to say is valuable. Taking the time to perfect this skill is well worth the effort, and not only informs a patient’s care but helps to develop trust and connection between physician and patient.