Patient History Taking [Explained]

In today’s micro-lecture, Australian Paramedical College Hon. Snr. Lecturer Sam Willis talks the importance of patient history taking to help paramedics make the right decisions about what to do to treat the patient, how quickly it’s needed to be done and whether or not the patient needs to be referred onto a specialist type service.

Today, we’re going to talk about the importance of history taking. Now, you will have heard me say time and time again, that 80% of what we do as paramedics is history taking. That leaves an extra 20% of actually doing something like an assessment, a physical assessment or another type of physical intervention. Now, what you will find is that when you arrive on scene at your patient’s side, you’ve never usually met them before. There are occasions when you have, and that’s great, but on most occasions you’ve never met the patient before. So what you have to do is take these small parts of the Jigsaw and put them together to give you a bigger picture so that will help you guys as paramedics to make the right decisions about what you are going to do to treat your patient, how quickly you need to do it, and whether or not they need to be referred onto a specialist type of service.

Just remembering that paramedicine is continually changing and there’s becoming more and more referral pathways. So history taking is so important. So let’s go and use this history taking format here as a way of starting to introduce you to the importance of history taking. Now, the first thing you see on here is the chief complaints. Now the chief complaint is the reason you guys have been called. So is it chest pain? Is it shortness of breath? You need to start asking questions about it. So when did it start? What were you doing when it came on? Have you ever had this before? If so, when was it? How did you get it treated? What medications are you taking for this condition? So really focused in on the chief complaint.

History of presenting illness. We’ve already started talking about that. Have you had this before? When did you have it before? Was it days, was it weeks, was it months or is this the first time you’ve ever had this? What’s your past medical history? So not just your past medical history in terms of I’ve got asthma or I’ve got diabetes, but also childhood. Have you had all your childhood immunisations? What about your medical history? Surgical, have you had any recent surgeries? Because believe it or not, there are conditions that you will be called to that are really related to a recent surgery, the biggest one of course being post surgical infections. OBs and gynecologically related conditions in women.

Psychiatric history, mental health is hugely important. Now, of course you will approach this one very carefully, but just say, “Do you have any mental health history? Are you taking any medications? Are you referred? Have you been referred recently to a psychiatric, to mental health care?” Try and avoid psychiatric because it’s a little bit impersonal. What about family history? Are there any conditions that run in your family, diabetes, strokes, epilepsy, anything like that? What are your medications? Have you been taking them? When were you prescribed them? How long have you been taking them for? Do they interact with anything? Have there been any changes to your medications? Do you have any allergies? If so, what happens when you have this certain thing that you’re allergic to?

Personal and social history. Do you live alone? Do you socialize? Do you go out to the pub? How often do you drink? How often do you smoke? Of course, a review of systems. Are you taking any medications for heart? Are there any problems with your heart that you’re aware of? Of course you as the paramedic can do a physical assessment of the systems if it’s indicated. So that’s basically a snapshot into history taking. Hope you’ve enjoyed the micro lecture on history taking.

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