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CLINICAL HISTORY TAKING (STRUCTURE), Mauren Michelle Lopez Martinez 26988…
CLINICAL HISTORY TAKING (STRUCTURE)
The clinical history is the
most important
aspect of the interaction between patient and doctor
Taking a clinical history from a patient is
a skill necessary that test:
Your
communication
skills
Your
knowledge
about what to ask
The clinical history has a well formulated structure to help determine:
To establish
any other
relevant information
Aid in the
diagnosis (80%)
Patients problems in a
logical order
STEP 1
Initiating the session
Introduce yourself
Hello Ms. Jones, I am doctor Smith, please have a seat
Identify your patient
You are Sandra Jones, is that right?
Call the patient into the office/examination room
Ms. Jones, come in please
Gain consent
Can i ask you some questions and write them down?
STEP 2
Presenting complaint/chief complaint (PC)/(CC)
Why he or she is coming to see you
Chest pain, stomachache, cough, fever, etc
Opening question
What is troubling you?
What problems do you have?
How can i help you?
This is when the patient
tells you what is wrong
Screening and confirming
To make sure we have the correct symptoms
To make sure the patient told us everything
So, you have chest pain, anything else?
So, you have a stomachache and fever, anything else you want to talk about?
Setting the agenda
Preparing the patient for the HPC or HPI
Lets us start with the stomachache and then we will talk about the fever
Is that okay?
Okay, now i will ask you some questions about each of your symptoms
Mauren Michelle Lopez Martinez
26988
INGLES II T2