pt assess history taking
DESCRIPTION
TRANSCRIPT
PARAMEDIC CARE:PRINCIPLES &
PRACTICE
Patient Assessment
The History
The ability to elicit a good history lays the foundation
for good patient care.
Source of History
Patient Family Friends Police Others
Setting the Stage
If a patient’s chart is available, review it before interviewing the patient.
Use this information to gain clues about the patient.
Reliability
Memory Trust Motivation
Patient Rapport
The First Impression
Present yourself as a caring, competent, and confident health care professional.
When you introduce yourself to the patient, shaking hands or offering a
comforting touch will help build trust.
Asking Questions
Use a combination of open-ended and close-ended questions.
Language and Communication
Use appropriate language. Use an appropriate level of
questioning, but do not appear condescending.
When encountering communication barriers, try to enlist someone to help.
Actively listen.
Active Listening
Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
Sensitive Topics
A paramedic must learn to become comfortable dealing with sensitive topics.
It is important to earn a patient’s trust.
The Comprehensive Patient History
Elements of the Patient
History
Preliminary Data
Date and time Age Sex Race Birthplace Occupation
The Chief Complaint
This is the pain, discomfort, dysfunction that caused the patient to request help.
The Present Illness OPQRST-ASPN
Onset of the problem
Provocative/
Palliative factors Quality Region/Radiation Severity Time
Associated Symptoms
Pertinent Negatives
Past History General state of health Childhood diseases Adult diseases Psychiatric illnesses Accidents or injuries Surgeries or hospitalizations
Current Health Status
(1 of 3)
Current medications Allergies Tobacco Alcohol, drugs, and
related substances Diet Screening tests Immunizations
Current Health Status
(2 of 3)
Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and
significant others Daily life
Current Health Status
(3 of 3)
Important exercises Religious beliefs The patient’s outlook
You should take your patient’s medications with you to the
hospital, when practical.
Review of Systems
A system-by-system series of questions designed to identify problems your patient has not already identified.
Systems
General Skin HEENT Respiratory Cardiac Gastro-Intestinal
Urinary Male/Female
Special Challenges (1 of 2)
Silence Overly talkative
patients Multiple
symptoms Anxiety
Depression Sexually
attractive or seductive patients
Confusing behaviors or symptoms
Special Challenges (2 of 2)
Patients needing reassurance
Anger and hostility
Intoxication Crying
Limited intelligence
Language Barriers Hearing problems Blindness Talking with
families or friends
If the patient cannot provide useful information, gather it
from family or bystanders.
Summary
History taking techniques Active listening The comprehensive health
history