Medical record, medical history and interviewing technique

Chapter 1 Medical record, medical history and interviewing technique



CONSULTATION, MEDICAL HISTORY AND RECORD-TAKING


The ability to take an accurate medical history from a patient is one of the core clinical skills and an essential component of clinical competence. The success of the medical consultation depends not only on the doctor’s clinical knowledge and interview skills but also on the nature of the relationship that exists between doctor and patient. Patients need to feel sufficiently at ease to disclose their problems and express their concerns, and to know they have been understood by the doctor. Patients also need to reach a shared understanding with the doctor about the nature of their illness and what is proposed to deal with it.


In any consultation the doctor has a number of tasks to perform. Ideally these should be undertaken in a structured way so as to maximise the efficiency and effectiveness of the process. A number of consultation models exist but an increasingly influential model is the Calgary-Cambridge approach. This identifies five main stages in a consultation within a framework which provides structure and emphasises the importance of building a good doctor–patient relationship. The stages are:


• initiating the session

• gathering information

• physical examination

• explanation and planning

• closing the session

This chapter primarily addresses the first two stages – initiating the session and gathering information. In addition it describes an approach to recording information from the consultation in the clinical record.



INTERVIEWING TECHNIQUES AND HISTORY-TAKING


The medical consultation is the main opportunity for the doctor to explore the patient’s problems and concerns and to start to identify the reasons for the patient’s ill health. Models of history-taking are becoming more patient-centred and seeking to assess both main components of ill health – the biomedical component and the psychosocial component.



STARTING THE CONSULTATION


There are three main aspects to initiating the session: preparation, establishing initial rapport, and identifying the patient’s problems/concerns.



Preparation


In preparing for a consultation, you should plan for an optimal setting – ideally a location that is quiet and free from interruption. Most patients have clear expectations of what constitutes appropriate dress and appearance. Given this, you should adopt a dress code which projects a professional image and allows patients to feel comfortable in your presence. This may vary according to setting and patient group.



Initial rapport


On first meeting a patient it is important to establish rapport and put the patient at ease. You should greet the patient, introduce yourself and clarify your role, giving the patient an outline of what you intend to do. The first contact should also be used to obtain/confirm the patient’s name, and to check how the patient prefers to be called.



Identifying the patient’s problems and concerns


Begin by asking patients to outline their problems and concerns by using an open-ended question (e.g. ‘Tell me what has brought you to the doctor today’). Remember patients may have more than one concern they wish to raise and discuss. The order of their problems may not relate to their importance from either the patient’s or doctor’s perspective. It is therefore particularly important in this opening phase not to interrupt the patient in case this inhibits the disclosure of important information.


Once the problems have been identified it is worth taking some time to check that you have understood correctly by summarising and repeating back to the patient. It is also good practice to check for additional concerns: ‘Is there anything else you would like to discuss?’.



GATHERING INFORMATION – THE HISTORY



Exploration of the patient’s problems


You now need to explore each of the patient’s problems in greater detail from both biomedical and psychosocial perspectives. In doing so you should seek to avoid medical jargon, combine both open and closed questions, and summarise your understanding of the patient’s problems (this allows the patient an opportunity to check you have understood correctly).



Biomedical perspective


Questions on the biomedical perspective should seek to clarify the sequence of events and help inform an analysis of the cause of the symptoms. Symptoms from an organ system have a typical location and character: chest pain may arise from the heart, lungs, oesophagus or chest wall but the localisation and character differ. Establish the location of the symptom, its mode of onset, its progression or regression, what it feels like, and aggravating or relieving factors. Enquiry should also be made about associated symptoms.




imageSymptoms and signs: Five fundamental questions you are trying to extract for the history



• From which organ(s) do the symptoms arise?

• What is the likely cause?

• Are there any predisposing or risk factors?

• Are there any complications?

• What are the patient’s ideas, concerns and expectations?


imageSymptoms and signs: Pain assessment



• Type

• Site

• Spread

• Periodicity or constancy

• Relieving factors

• Exacerbating factors

• Associated symptoms

For the assessment of pain, use the framework shown in the box above. Ask whether medication has been necessary to alleviate the pain and whether the pain interferes with work or other activities. It is difficult to assess pain severity. Offering a patient a numerical score for pain, from ‘0’ for no pain to ‘10’ for excruciating pain, may provide a quantitative assessment of the symptom.



Psychosocial perspective


Information on psychosocial perspectives of a problem requires questions to be asked about a person’s ideas, concerns, expectations and the effect of the problem on his or her life. For example, if you wanted to explore a patient’s psychosocial perspectives of headaches, potential questions include: ‘what concerns you most about the headaches?’, ‘what do you think is causing the headache?’, ‘is there some specific treatment you had in mind?’, and ‘how do the headaches affect your daily life?’.


Combining information on psychosocial perspectives with biomedical information aids diagnosis and helps to provide a foundation for decisions about the future management of a problem.



Background information


The information that is gathered about a patient’s problems needs to be set in the context of the individual. Contextual information requires enquiry into a person’s family history, personal and social history, past medical history and drug and allergy history.



Family history


Ask about any disorders that might be inherited, social partnerships (e.g. does the patient have a regular partner, is the patient married) and children. It may be helpful to construct a family tree (Fig. 1.1).


image

Fig. 1.1 A standard family tree.



Personal and social history


Enquire about education, employment (past and present – is there suspicion of exposure to an occupational hazard?), social support networks, home circumstances (does the patient live alone? Can the patient attend to his or her personal needs – bathing, cooking? Are there financial worries?).


Also at this point ask about tobacco and alcohol.



TOBACCO CONSUMPTION


Ask patients what form of tobacco they consume and for how long they have been smoking. If they previously smoked, when did they stop and for how long did they abstain?



ALCOHOL CONSUMPTION


Alcohol history is often inaccurate and the tendency is to underestimate intake. Calculate the amount in units. Certain questions may reveal dependency without asking the patient to specify consumption. Ask whether they ever drink alone or during the course of the day as well as the evenings. Do they have days without alcohol? Has anyone ever expressed concern about their drinking? Have they ever failed to do what was expected of them because of their drinking?



imageSymptoms and signs: Units of alcohol equivalents (approximate)



1 unit is equal to:



• 1/2 a pint of beer

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Medical record, medical history and interviewing technique

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