Learning to take a good history is crucial to determine a diagnosis and subsequent treatment plan. History taking also enables you to build a rapport with the patient through good communication skills. This post will cover the basic areas to cover in your history taking.
Always introduce yourself to the patient, this includes your name AND your position. Additionally, this is the point at which to gain consent from the patient to continue asking them questions, e.g. “I understand you’re having some trouble, am I okay to ask you about this?”.
Presenting Complaint (PC)
This is what the patient says is the problem, generally in their own words e.g. “My front tooth aches”.
History of Present Complaint (HPC)
This is where we expand on the patient’s PC. Generally, complaints will be of pain and the common acronym used is SOCRATES:
- Site: the location of the pain
- Onset: when did the pain begin?
- Character: how would they describe the pain? e.g. sharp or dull
- Radiation: is the pain spreading elsewhere?
- Associated features: is there anything else going on? e.g. swellings, bad taste
- Time: has the pain changed over time in things like severity or character?
- Exacerbating/Alleviating factors: what makes the pain better/worse?
- Severity: how severe is the pain – often good to record this as a number from 1 to 10.
This structure will ensure you cover all the major features of the complaint and therefore help to allow you to establish a diagnosis.
Past Medical History (PMH)
It’s also important to inquire about any other medical conditions the patient may suffer with. This may be useful information to help towards diagnosis, e.g. anaemia, or important for future treatment decisions. Often it’s good to go through a systems overview of the body in case the patient has missed something: cardiovascular and haematological, respiratory, GI, neurology, renal etc. Simple questions like “any heart problems? any breathing problems?”.
Always check if the patient has any allergies – to medication or otherwise.
Drug History (DH)
Check the patient’s current medications, as accurately as possible, including dosages. Often patient’s don’t mention over-the-counter medication and non-prescription medications so be careful! If you don’t know what a medication is then CHECK THE BNF!
Past Dental History (PDH)
If the complaint may be tooth related, it can be useful to inquire about any dental treatment the patient may have had. Additionally, it’s important to gauge the patient’s attitude towards the dentist and whether they may be anxious or receptive to treatment.
Family History (FH)
Check the patient’s family history of common conditions, including diabetes and cardiac problems. Additionally, it is important to identify any genetic problems that run in the family.
Social History (SH)
Some important information you want to collect at this point includes:
- Smoking history – are they a current or ex-smoker? how much did they smoke?
- Alcohol consumption – ideally in units
- Living arrangements – do they have support if they need it?
- Occupation – this may help establish a diagnosis or affect treatment plans
It is crucial to check all the information you have collected from the patient. This is useful for TWO reasons: you can check the accuracy of the information AND it shows to the patient that you have listened to them. If you do not have the time to check the entire history, the minimum would be to check the PC and HPC.
Finally, allow the patient to express any concerns or questions they may have an address them as necessary.