1. EMS 351 Lecture (4)
HISTORY TAKING
DR. SAMAH MOHAMMED

2. Learning Objectives List purpose of taking history.
Explain sample history.
Discuss way of past history.
Explain techniques of therapeutic communication.

3. History Taking The purpose of obtaining a history is to:
Gather a systematic account of past medical conditions, illnesses, and injuries.
Determine the events leading up to the present medical situation.
Determine the signs and symptoms of the current condition.

4. History Taking Gain information about the patient and the events:
Investigation of the chief complaint.
Mechanism of injury/nature of illness.
Past medical history.
Components of the patient history.
Interviewing techniques.
How to integrate therapeutic communication techniques. 4

5. Chief complaint The patient chief complaint is the most serious thing.
Should be recorded in patient’s own words.
Should include:
What is wrong.
Why treatment is being. 5

6. Sample history Signs / Symptoms Allergies Medications
Sample history includes
Signs / Symptoms
Allergies
Medications
Pertinent Past History
Last Oral Intake
Events (injury/ illness)

7. Sample History Signs / Symptoms: Allergies: Medications:
What signs and symptoms occurred at the onset of the incident? Does the patient report pain?
Allergies:
Is the patient allergic to any medication, food, or other substance? What is reaction?
Medications:
What medication is patient prescribed? What dosage is prescribed? How often does the patient take medication? 7

8. Sample History Pertinent Past History: Last Oral Intake:
Does the patient have any history of medical, surgical , trauma? Has patient fall, , illness?
Last Oral Intake:
When patient last eat or drink? What did patient eat or drink? Does patient take any drugs or alcohol?

9. Sample History Events (injury –illness):
Can be assessment of pain is the OPQRST
Onset: when did the problem begin and what caused it?
Provocation: Does any thing make it feel better or worse? How are you most comfortable
Quality: what is the pain like? And describe the pain?
Region/radiation/ referral: where does it hurt? Does the pain move anywhere?
Severity: on a scale of 1 to 10, how would you rate your pain?
Timing: how long have you had the pain? When did the pain start?

10. Past medical history Should include: Current medications and dosages.
Allergies.
Childhood illnesses.
Adult illnesses.
Past surgeries.
Past hospitalizations and disabilities. 10

11. Taking History on Critical Topics
Alcohol and drugs
Signs may be confusing, hidden.
History may be unreliable
Physical abuse or violence
Report all physical abuse or violence.
Follow local protocols.
Sexual history
Ask all patients about the potential for sexually transmitted diseases.

12. TAKING HISTORY Current health status Social history Smoking habits.
Alcohol and drug use , Sexual habits.
Diet, Occupation , Environment.
Family history
Helps establish patterned and risk factors for potential diseases.
Information should be related to the patient’s current medical condition.
Current health status
together past history with history of current event. 12

13. Techniques for History Taking
Appearance
Clean, neat, and professional.
Good attitude
Identify your service and certification level.
Try to interview in a private setting.
Note taking
Let the patient know that you will be writing information down.
Position yourself at eye level.
Maintain good eye contact. 13

14. Techniques for History Taking
Privacy
Be familiar with relevant laws.
Be familiar with the cultural groups in area.
Reviewing medical history and information reliability
Document the source of all information.
During routine transfers, look over paperwork.
Evaluate your sources for reliability. 14

15. Communication Techniques
Empathetic response
Put yourself in the patient’s.
Encourage dialogue.
Encourage the patient to express his feeling.
Ask about feelings.
Tired, depressed, etc.
Validate the patient’s feelings. 15

16. Communication Techniques
Getting more information
Question location of pain.
Question quality of abdominal pain.
Add, delete, and modify questions.
Avoid close-ended and leading questions.
Try to be orderly and systematic.
Asking direct questions
If you need a date, time, etc., ask for it 16

17. Communication Techniques
Applying clinical reasoning
Critical thinking consists of:
Concept formation
Data interpretation
Application of principles
Reflection in action
Reflection on action
Think and perform well under pressure.
Be a patient listener.
Communicate with patients.
Look for nonverbal communication 17

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