{"id":600,"date":"2023-09-04T15:38:00","date_gmt":"2023-09-04T15:38:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=600"},"modified":"2026-02-19T16:32:49","modified_gmt":"2026-02-20T00:32:49","slug":"11-tips-for-taking-a-patient-history","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history","title":{"rendered":"11 Tips for Taking a Patient History"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#1_Preparation_Environment\" >1. Preparation &amp; Environment<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#2_Establish_Effective_Communication\" >2. Establish Effective Communication<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#3_Components_of_Taking_a_Good_Medical_History\" >3. Components of Taking a Good Medical History<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#4_Use_Open-Ended_Questions_and_Follow-ups\" >4. Use Open-Ended Questions and Follow-ups<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#5_Sensitivity_to_Individual_Patient_Culture_and_Identity\" >5. Sensitivity to Individual Patient Culture and Identity<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#6_Address_Health_Literacy\" >6. Address Health Literacy<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#7_Pay_Attention_to_Non-Verbal_Cues\" >7. Pay Attention to Non-Verbal Cues<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#8_Recognizing_Red_Flags_and_Critical_Symptoms\" >8. Recognizing Red Flags and Critical Symptoms<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#9_Documentation_and_Record-Keeping\" >9. Documentation and Record-Keeping<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#Subjective_Findings\" >Subjective Findings<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-11\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#Objective_Findings\" >Objective Findings<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-12\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#Assessment\" >Assessment<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-13\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#Plan\" >Plan<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-14\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#10_Involve_Patients_in_the_Process\" >10. Involve Patients in the Process<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-15\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#11_Continuous_Learning_and_Improvement\" >11. Continuous Learning and Improvement<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-16\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#How_to_Apply_What_Youve_Learned\" >How to Apply What You&#8217;ve Learned<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-17\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#Key_Takeaways\" >Key Takeaways<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-18\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\">Taking a comprehensive and complete <strong>medical history<\/strong> is one of the most important skills you\u2019ll learn as a medical student and junior doctor. A good history, paired with a proper <strong>clinical examination<\/strong>, can be the key to diagnosing exactly what\u2019s happening with a patient. It can help uncover relevant insights and assist in making well-informed decisions about care. Delving into <strong>past medical conditions, family history, lifestyle factors, <\/strong>and <strong>existing symptoms<\/strong> enables providers to identify risk factors, diagnose conditions accurately, and develop personalized treatment plans. Taking the time to learn about your patients helps <strong>establish rapport and trust<\/strong> by showing them you value what they say and are experiencing.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"1_Preparation_Environment\"><\/span>1. Preparation &amp; Environment<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Before you step into the exam room, prepare yourself. Make sure you have a pen and paper or that you\u2019ve opened their electronic record to accurately record what they tell you. Take the time to read any patient\u2019s 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\u2019re meeting. If you\u2019re likely to receive calls during the interview, explain that to them in advance. <strong>Your patients should feel that you\u2019re giving them your full attention.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">First impressions count no matter what anyone says, so do all you can to make a good one. <strong>Introduce yourself and explain your position<\/strong> (medical student, resident, attending, etc.). <strong>Ask how they\u2019d like to be addressed.<\/strong> Some people are happy with first names, while others prefer a more formal approach.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Circumstances often dictate the environment. For example, don\u2019t 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\u2019d like an extra blanket or pillow. <strong>Sit close enough so that you can easily hear each other.<\/strong> Make sure that you\u2019re comfortable as well.<\/p>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"503\" height=\"750\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/speech-bubbles.png\" alt=\"A collection of speech bubbles, representing communication.\" class=\"wp-image-7777\" style=\"width:281px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/speech-bubbles.png 503w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/speech-bubbles.png?resize=201,300 201w\" sizes=\"auto, (max-width: 503px) 100vw, 503px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"2_Establish_Effective_Communication\"><\/span>2. Establish Effective Communication<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">When it comes to <strong>patient interview techniques<\/strong>, never underestimate how effective a <strong>smile<\/strong> can be in reassuring someone. Many patients are nervous and worried, so taking a few moments to reassure them before starting the interview will help put them at ease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Be clear about why you&#8217;re there, tell them what you\u2019ll ask them, and why it\u2019s important. Explain that you want to hear what\u2019s been going on with their health in their own words. Confirm that they understand what you\u2019ve 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\u2019t understand anything throughout the interview, make sure they\u2019re empowered to speak up and ask you about it.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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&#8217;s <strong>social history<\/strong> often provides invaluable information when building a picture of the patient, so don\u2019t skip over it. <strong>Take the time to learn who they are as a person.<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Clinician&#039;s Corner: Taking a good patient history\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/4wfjSfoHwl4?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"3_Components_of_Taking_a_Good_Medical_History\"><\/span>3. Components of Taking a Good Medical History<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">By the time you\u2019re treating real patients, you\u2019ll be more than familiar with the components of a&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Clinician's_Corner:_Taking_a_good_patient_history\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>good medical history<\/strong><\/a>:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Patient Identification and Demographics&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Chief Complaint and Presenting Symptoms&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Past Medical History (PMH)&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Family History (FH)&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Social History (SH) and Lifestyle Factors&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Medications and Allergies&nbsp;<\/strong><\/li>\n\n\n\n<li><strong><a href=\"https:\/\/www.osmosis.org\/blog\/2021\/11\/01\/importance-of-review-of-systems\">Review of Systems<\/a>&nbsp;(ROS)<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">While all of these elements are important, don\u2019t feel like you have to stick to this exact structure. <strong>Let each person tell their story.<\/strong> Sometimes, it\u2019s more natural to change the structure so that you hear the story in their own words.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"4_Use_Open-Ended_Questions_and_Follow-ups\"><\/span>4. Use Open-Ended Questions and Follow-ups<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Always start with <strong>open-ended questions<\/strong>. The idea is to hear what people are experiencing in their own words. Try to listen and hold your questions until they&#8217;ve finished sharing their story. When there&#8217;s an aspect of their story you&#8217;d like to learn more about, <strong>make a note and come back to it<\/strong> once the patient has finished sharing.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For example, follow up with questions like. \u201cYou 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?\u201d Give them the opportunity to paint the broad picture, then go back and <strong>fill in the details<\/strong>. Consciously work to <strong>avoid asking leading questions<\/strong> or questions that suggest an answer or are biased toward a particular response.<\/p>\n\n\n\n<figure class=\"wp-block-image alignright size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"470\" height=\"750\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/woman-sitting-with-clipboard-hijab-muslim.png\" alt=\"Nurse wearing a hijab sitting in a room with a patient, reviewing the patient's chart. She's there at the patient's request for women-only providers.\" class=\"wp-image-7779\" style=\"width:331px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/woman-sitting-with-clipboard-hijab-muslim.png 470w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2023\/09\/woman-sitting-with-clipboard-hijab-muslim.png?resize=188,300 188w\" sizes=\"auto, (max-width: 470px) 100vw, 470px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"5_Sensitivity_to_Individual_Patient_Culture_and_Identity\"><\/span>5. Sensitivity to Individual Patient Culture and Identity<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"margin: 0px;padding: 0px\">People come from a variety of\u00a0<a href=\"https:\/\/www.osmosis.org\/blog\/2023\/08\/22\/what-is-intersectional-healthcare-and-why-is-it-important\" target=\"_blank\"><strong>cultural backgrounds<\/strong><\/a>, and clinicians must be <strong>sensitive <\/strong>to that throughout a <strong>patient interview<\/strong>. <strong>Respect your patient&#8217;s values and beliefs.<\/strong> Remember that interactions that are acceptable for one person may not work for another. Most importantly, note that caregivers and clinicians are responsible for learning how to relate to patients in ways that help them feel <strong>seen, heard, and accepted<\/strong> as part of their care.<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">These conversations can be especially challenging when there are <strong>specific medical questions<\/strong> that you need to explore that may be at odds with your patient\u2019s identity or beliefs. The best way to address sensitive issues is to be <strong>direct with kindness<\/strong>. Explain that it\u2019s essential to ask them about a topic they may be sensitive to because knowing their answers is integral to understanding who they are and how to manage their care.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"6_Address_Health_Literacy\"><\/span>6. Address Health Literacy<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Everyone has varying degrees of <strong>health literacy<\/strong>, so don\u2019t make the mistake of assuming patients understand what you\u2019re telling them. Make sure your word choices are <strong>appropriate for both the age and cognitive ability<\/strong> of each individual. Wherever possible, use plain terminology (e.g., &#8220;heart attack&#8221; rather than &#8220;<a href=\"https:\/\/www.osmosis.org\/learn\/Myocardial_infarction\" target=\"_blank\" rel=\"noreferrer noopener\">myocardial infarction<\/a>&#8220;) and <strong>avoid the use of medical jargon or terms<\/strong>. Encourage patients to ask questions if they\u2019re unsure of what you mean or need clarification. Make use of <strong>visual aids and diagrams<\/strong> to explain medical concepts. <strong>Ask them to reflect or repeat<\/strong> <strong>what they\u2019ve heard you say<\/strong> to confirm they understand what you\u2019ve said to them.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"7_Pay_Attention_to_Non-Verbal_Cues\"><\/span>7. Pay Attention to Non-Verbal Cues<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">While interpersonal or <strong>clinical communication skills<\/strong> don&#8217;t come naturally to everyone, it&#8217;s important to actively learn and apply them in practice with your patients.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">There are times when what someone doesn\u2019t 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 <strong>non-verbal cues<\/strong> (e.g., restlessness or eye contact avoidance); they often provide valuable insights into what is going on in their lives.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">It\u2019s always essential to note if the non-verbal cues are at odds with what they&#8217;re saying. If you observe that their body language seems to be saying something else, don\u2019t put them on the spot. Instead, add it to the collection of information you\u2019re learning about them, and maybe, if the time is right at a later date, explore it further.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">When people are telling you their story, it can be an emotional journey for them. Prepare yourself for this, as it\u2019s important for you to respond appropriately. Also, keep in mind that <strong>empathy differs from sympathy<\/strong>; both terms relate to care and concern for others and a desire for their well-being. However, <strong>empathy is relating to their feelings and experiences<\/strong>, while <strong>sympathy is feeling for their situation<\/strong> (e.g., pity).\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"8_Recognizing_Red_Flags_and_Critical_Symptoms\"><\/span>8. Recognizing Red Flags and Critical Symptoms<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">There are times when a patient may disclose what\u2019s known as a <strong>red flag<\/strong> or a <strong>critical symptom<\/strong>. Frequently, they may not come straight out and say it but discuss it in their own words. <strong>Pay close attention<\/strong> to their story, and if you believe they\u2019re raising a critical symptom, <strong>explore it further<\/strong>. Because if they raise an issue that\u2019s considered a red flag, it\u2019s vital that you <strong>act decisively and appropriately<\/strong>. Which typically means seeking immediate medical intervention or promptly referring a high-risk patient to a specialist. <strong>Document precisely<\/strong> what they&#8217;ve said when seeking an intervention or urgent referral.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Most importantly, if you\u2019re unsure, don\u2019t just document it in the notes. <strong>Take the next step and seek the advice of your supervisor. It could save a life!<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image alignleft is-resized\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/DbAYdnMbSciGPkFGpvYP5rjMTIGiEvJE\/_.png\" alt=\"An illustration of a Progress Note which includes a space for Patient Name, Patient Signature, Notes, Date, Subjective, Objective, Assessment, and Plan.\" style=\"width:335px;height:auto\"\/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"9_Documentation_and_Record-Keeping\"><\/span>9. Documentation and Record-Keeping<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">It\u2019s vital that you\u00a0<a href=\"https:\/\/www.osmosis.org\/blog\/2018\/12\/07\/3-tips-to-write-progress-notes\"><strong>document all your interactions<\/strong><\/a>\u00a0with your patients and <strong>keep a clear record<\/strong> of what they&#8217;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 <strong>SOAP<\/strong>, which organizes your notes as follows:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Subjective_Findings\"><\/span>Subjective Findings<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Information that the patient has told you. This section can be organized into sub-headings, such as presenting a complaint, family history, etc.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Objective_Findings\"><\/span>Objective Findings<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Includes your observations and the results of any clinical examination, lab results, or imaging.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Assessment\"><\/span>Assessment<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Where to put it all together! Gather your thoughts and make an assessment of what you think is happening for the patient.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Plan\"><\/span>Plan<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Where you write what you plan to do next, and may include any tests you consider necessary, social interventions, further assessments, and so on.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Following the <strong>SOAP<\/strong> <strong>format <\/strong>makes it easy for other staff members to see what\u2019s been done and what else is necessary to diagnose and treat the patient.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"10_Involve_Patients_in_the_Process\"><\/span>10. Involve Patients in the Process<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">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\u2019re being heard, treated with respect, and that their input is valuable. Remember to discuss any decisions with them and ensure they\u2019re part of the <strong>decision-making process<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"11_Continuous_Learning_and_Improvement\"><\/span>11. Continuous Learning and Improvement<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Practice taking patient histories<\/strong> whenever the opportunity arises. Not only does it help you <strong>improve your clinical skills<\/strong>, it helps to <strong>make you feel more comfortable<\/strong> with the process.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Don\u2019t be afraid to <strong>take the lead on rounds<\/strong> when called upon. Your colleagues can help by critiquing your performance and providing ideas on how you might improve certain aspects. <strong>Watching your colleagues<\/strong> can also help you discover different ways of doing things that might be more natural.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">After completing a patient history, it\u2019s often useful to <strong>spend five minutes talking with a peer or supervisor<\/strong> to evaluate your performance and consider what aspects you could have handled better or differently.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"How_to_Apply_What_Youve_Learned\"><\/span>How to Apply What You&#8217;ve Learned<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Being able to take a <strong>good patient history<\/strong> 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The process of taking a <strong>medical history<\/strong> 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&#8217;s care but helps to develop trust and connection between you and your patient.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Key_Takeaways\"><\/span>Key Takeaways<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Prepare well and minimize distractions before patient interviews.<\/strong><\/li>\n\n\n\n<li><strong>Use open-ended questions and listen actively to build rapport.<\/strong><\/li>\n\n\n\n<li><strong>Be sensitive to cultural differences and patient preferences.<\/strong><\/li>\n\n\n\n<li><strong>Observe non-verbal cues and respond with empathy.<\/strong><\/li>\n\n\n\n<li><strong>Document histories clearly using structured formats like SOAP.<\/strong><\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7152492\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7152492\/<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.prismcareerinstitute.edu\/blog\/taking-patient-history\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.prismcareerinstitute.edu\/blog\/taking-patient-history\/<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/everynurse.org\/7-steps-culturally-sensitive-nurse\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/everynurse.org\/7-steps-culturally-sensitive-nurse\/<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.wolterskluwer.com\/en\/expert-insights\/how-physician-body-language-can-affect-patient-interactions\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.wolterskluwer.com\/en\/expert-insights\/how-physician-body-language-can-affect-patient-interactions<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK534249\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK534249\/<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.scripps.org\/news_items\/6473-how-to-know-if-your-medical-concern-is-an-emergency\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.scripps.org\/news_items\/6473-how-to-know-if-your-medical-concern-is-an-emergency<\/a><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/stay-a-step-ahead-banner.png\" alt=\"\" class=\"wp-image-601\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/stay-a-step-ahead-banner.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/stay-a-step-ahead-banner.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<em><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a><\/em>\u00a0and discover why millions of current and future <strong>clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A comprehensive medical history is vital for an accurate diagnosis, developing personalized treatment plans, and establishing a good rapport with your patients. On today\u2019s Osmosis blog, let&#8217;s take note of\u00a0some helpful tips for recording a high-quality medical history.<\/p>\n","protected":false},"author":176,"featured_media":8874,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,10,14,21,30,16,37,32],"tags":[218,413,147,408,245,149,409,1691,412,411,410],"class_list":["post-600","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-clinical-skills","category-dental","category-guides","category-np","category-do","category-pa","category-nursing","tag-clinical-skills","tag-documentation","tag-healthcare-communication","tag-medical-history","tag-nursing-education","tag-patient-care","tag-patient-interview","tag-patient-interview-techniques","tag-physician-patient-relationship","tag-rapport-building","tag-soap-notes"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>11 Tips for Taking a Patient History - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/11-tips-for-taking-a-patient-history\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"11 Tips for Taking a Patient History - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A comprehensive medical history is vital for an accurate diagnosis, developing personalized treatment plans, and establishing a good rapport with your patients. 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