Chapter 12. History Taking. Objectives. Patient History Process
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1 Chapter 12 History Taking Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Objectives 1. Describe the role of the radiologic technologist in taking patient clinical histories. 2. Describe the desirable qualities of a good patient interviewer. 3. Differentiate objective from subjective data. 4. Explain the value of each of the six categories of questions useful in obtaining patient histories. 5. Describe the importance of clarifying the chief complaint. 6. Detail the important elements of each of the sacred seven elements of the clinical history. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Patient History Process Look at taking a patient history as an interview of the patient. In many cases the radiologic sciences professional is the eyes, ears, and mouth of the radiologist. Possessing good history-taking skills is an essential responsibility of the radiologic and imaging sciences professional. Information gathered needs to be accurate and specific in detail, if possible. Genuine interest in what the patient has to say, attentiveness, and an aura of professional competence can provide patients with a real sense of caring. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 1
2 Qualities of Interviewer Acknowledge patient s anger, if present Respect for patient Be genuine Empathy (not sympathy) for patient s condition Patients need to feel the information they are providing is important Don t intimidate patients Attention to detail Accurate note-taking skills Good questioning skills Multi-tasking, communication skills Maintain a polite and professional demeanor Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Data Collection Process Most patients understand the importance of a history and will provide information as requested. Remember, the information needed by the radiologist is specific to the patient s reason for the examination. Never disregard anything the patient says, especially if it does not fit with the opinion you are forming about the patient s symptoms. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Questioning Skills Use open-ended questions. Facilitate a response from the patient. Remain quiet to get a response. Use probing questions to focus in on more detail. Repeat patient response to clarify and confirm. Summarize to verify accuracy. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 2
3 Data Collection Process Objective Data Perceptible to senses Able to be measured Signs that can be seen, heard, felt, and so on Subjective Data Patient feelings Pain level Attitude Opinion of observer Subject to interpretation Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 What do radiologists want to know about the patient history? Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Why is this examination being done? Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 3
4 Elements of the Clinical History Chief Complaint MDs tend to focus on this. Permit the patient to add more than a single complaint when it appears multiple complaints are valid. Ignoring all symptoms except the most predominant can cause you to miss other important clinical information. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Sacred Seven of Medical Histories Localization Chronology Quality Severity Onset Aggravating or Alleviating Factors Associated Manifestations Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Patient History Considerations Does patient history data match requisition? Do symptoms support exam? Verify symptoms with exam request How would you describe pain? Localized vs. general Where How long Duration Old vs. new Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 4
5 Role of Technologist Act as good listener Take accurate notes and record them appropriately Essential responsibility of technologist Get answers to key clinical questions Present a professional image Important role in interacting with patient Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Conclusion Consider the patient history as an interview with the patient. Demonstrate respect, compassion, and empathy for the patient s condition. Clearly identify the patient s chief complaint. Gather all pertinent information relative to the procedure. Look for objective and subjective data. Present a professional image. Take accurate notes with attention to details. Never forget, you may be the eyes, ears, and voice of the radiologist with the patient. Copyright 2012, 2007, 2002, 1997, 1991, 1984, 1979 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 5
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