Patient interview and clinical history: Rad Tech

The patient interview and clinical history provide essential information for safe, accurate, and patient-centered imaging care.

Before you position the patient or begin the exam, the information you gather from the patient interview and clinical history helps you verify patient identity, confirm the ordered exam and clinical indication, confirm the correct procedure, recognize potential safety concerns, and better understand the patient’s condition and needs.

It also helps patients feel respected, and more comfortable during the imaging process.

As a radiologic technologist, your ability to communicate clearly and obtain a focused clinical history directly affects image quality, patient safety, and the healthcare team’s ability to make informed decisions about patient care.

As a radiologic technologist, you are the radiologist's eyes and ears.

Your primary goal during the interview is to obtain a clinical history focused on the patient’s immediate health concern and the reason for the requested imaging exam. A focused history helps the radiologist better understand the patient’s condition and supports accurate imaging and diagnosis.

Patient interviews can be organized using the sacred seven. These seven elements create a focused clinical history and include localization, chronology, quality, severity, aggravating or alleviating factors, onset, and associated manifestations.

Localization identifies the most specific point possible for the patient’s concern. For example, a patient may report abdominal pain but asking them to point to where the pain is strongest helps narrow the area of concern.

Chronology refers to the timing of symptoms, including when they began, how often they occur, how long they last, and whether they’re improving or worsening over time. For example, a patient may report abdominal pain that started 2 weeks ago, occurs daily, lasts 30 to 60 minutes, and becomes worse after meals.

Quality describes the character of the symptoms. For example, a cough may be wet or dry; a rash may appear red or raised; or pain may be described as sharp, dull, burning, throbbing, or stabbing.

Severity describes the intensity or extent of the problem. This may include a pain rating, the spread of a rash, or whether symptoms are mild, moderate, or severe.

Aggravating or alleviating factors are circumstances that make the symptoms worse or improve them. For example, pain may worsen after eating or improve with rest or a change in position.

Onset describes what the patient was doing when the symptoms first began. Understanding the onset can help identify activities or events that may trigger the condition.

Lastly, associated manifestations are additional symptoms that occur along with the chief complaint. Even if these symptoms do not seem related, they should still be documented because they may provide valuable clinical information.