Detailed history taking notes for health professionals and nurses

1. HISTORY TAKING
Prepared by: Pooja Koirala
Lecturer
NMCTH

2. Component of history taking
Biological information / patient identification data:
•Name
•Age
•Sex
•Education
•Marital status
•Occupation
•Religion
Provisional diagnosis
Ward
Bed number
Inpatient number (IP no.)
Attending doctor
Source of information
Date of admission (DOA)
Date of discharge

3. Chief complaint
• It is the main reason for pushing or coming to hospital or to seek for
visiting a physician or hospital
• Patient can have a single symptom or more than one symptoms /
complaints e.g. chest pain, shortness of breath, ankle swelling etc.
• The patient describes the problem in their own words
• It should be recorded in patient’s own words in a chronological order

4. Chief complaint cont…
Nurses questions the patient in following ways:
• What is troubling you?
• Describe the reason you came to the hospital or clinic today?
• What brings you here?

5. Chief complaint cont…
• It should be short / specific in one clear sentence.
• It typically follows the format as:
• Complaints × duration for which the problem has been
bothering the client.
• Example:
• C/O (complaining of) back pain since (×) 5 days
• Diarrhea × 3 days
• Vomiting × 1 day

6. History of present illness
• It is the elaborative form of the chief complaints which should be
chronological account of the major problems for which the patient is
seeking medical care.
• It should include the onset of problem (when did the problem started?), the
setting in which it developed, its manifestations and any treatments.
• It is necessary to collect the information regarding present illness to
strengthen the description of the chief complaint and to clarify its
relationship to other symptoms or problem that may be a clue to future
diagnosis.

7. Guidelines for assessment of present health
problems
Symptom analysis
• O: onset of disease or symptoms: it means the
time of starting of the symptom in the body
• P: proactive or palliative: it means what are the
causes of the symptoms? What makes it better or
worse?
• First occurrence: what were you doing when first
experienced or noticed the symptoms?
• Recurrence: what seems to trigger the problem?

8. • Q: quality or quantity: it means how the symptom feels,
looks or sounds. How much of it are you experiencing
now?
• Quality: how do you describe the symptom and how it feels,
looks or sounds?
• Quantity: how much are you experiencing now so that it
prevents you from performing activities? Is it more or less
than you experience at any other time?

9. • Regions, radiations, reliving or aggravating factors: it means
where the symptom is located. Does it spread?
• Region: where does the symptom occur?
• Radiation: in the case of pain, does it travel another part of your
body?
• Reliving or aggravating factors: any activities or position

10. • S: Severity: it means how the symptom rate is on a severity scale of 1
– 10, with 10 being the most extreme.
• Severity: how bad is the symptom rate is on a severity scale of 1 –
10, with 10 being the most extreme
• Course: does the symptom seem to be getting worse or staying
about the same?

11. • Timing: it means mode (form) of onset (abrupt or gradual),
progressing (continuous or intermittent). If intermittent ask
frequency / nature). How often does it occur.
• Onset: on what date did the symptom first occur? What time did it
begin?
• Type of onset: how did the symptom start: suddenly or gradually?
• Duration: how long does an episode of the symptoms last?

12. • Frequency: how often do you experience the symptom – hourly?
Daily? Weekly? Monthly?
• When do you usually experience it: during the day?
• Treatment received or (and outcome):

13. • A: are there any associated symptoms?
• List in a clear chronological order, details of the problems or
problems for while the patient is seeking care.
• For example:
• When and where did the problem begin?
• What kinds of symptoms did the patient experience?
• Has the patient taken any treatment for the problem

14. • What kinds of symptoms did the patient experience?
• Has the patient taken any treatment for the problem?
• Has the treatment had any effect on the patient or has
treatment not improved or altered patient ‘s condition?
• Ask the patient if the problem has affected the patient’s
lifestyle

16. HOPI for fluids (diarrhea, cough, vaginal
fluids)
• A: Amount
• B: Blood or other thing
• C: Color
• C: Consistency
• C: Content
• D: Duration
• O: Odor

17. Sample
• According to the mother, the child was active and playful 2 days back, then
she developed 8-9 episodes of vomiting, which initially contained the
ingested food material (milk) and later turned greenish and watery. It was
about 2 teaspoon full in each episode, foul smelling and non-projectile.
• After around 6 hours, the child developed diarrhea, 10-12 episodes/day,
watery with mucoid content, was foul smelling but did not contain blood in
the stool. The child cries while passing the stool but not during micturition.

18. Sample cont…
• There is also history of fever associated with diarrhea which was mild,
continuous and not associated with rash and abnormal body
movement.
• There is no loss of appetite, drinks vigorously. Mother gives history of
infrequent micturition compared to previous times.
• No cough, no shortness of breath.
• No loss of consciousness or avoidance of bright light.

20. 2. Past health history
• A comprehensive survey of a patient‘s past history
provides the information about patient’s major
health problems.
• Similarly, it also gives insight about the health
status of the patient up until now.
• Ask the patient about the
• Past medical history:
• Past surgical history

21. Past medical history
• About past hospitalization and reason of hospitalization
• Childhood illness: measles, malnutrition, mumps, whooping
cough, chicken pox, TB etc
• Immunization: complete / incomplete
• Adult illness / previous illness: such as IHD (Ischemic Heart
Disease), DM, asthma, TB
• Medications used:
• Allergic disorders: any allergic reaction to foods, drugs and
others

22. Past surgical history
• Ask the following:
• Any type of the surgery in the past e.g. ask time /place /
what type of operation etc.
• Injuries, trauma, accidents e.g. ask time/ place/ what
type of injuries and trauma etc
• Blood transfusion etc

23. Family history
• It includes the health history as well as their present state of health
of the 3 generations in order to identify the risk factors of certain
diseases.
• If death has occurred, then the cause of death is also assessed.
• One has to determine if certain common diseases run in the family
i.e. does a familial pattern exist?
• In this part of the history, you have to determine the age and health
of the parent's parent, grand parents, siblings, spouse and children
etc

24. Family history cont…
• Use written statement and diagram to record the family history
• Particular attention should be given to disorders such as heart
disease, cancer, diabetes, hypertension, obesity, allergies, arthritis,
tuberculosis, bleeding, alcoholism, and any mental health
disorders

26. Personal history
• Here the information about the patient’s lifestyle, occupation and
habits are obtained.
• Personal habit: the amount, frequency and duration of substance use
(tobacco, alcohol, coffee, cola, tea and illegal or recreational drugs)
are obtained
• Diet: description of a typical diet on a normal day or any special diet,
number of meals and snacks per day, who cooks and shops for food,
ethnic food patterns, and allergies

27. • Sleep patterns: usual daily sleep/wake times,
difficulties sleeping, and remedies used for difficulties
• Recreation/hobbies: exercise activity and tolerance,
hobbies and other interests, and vacations
• Questions include:
• What do you do for recreation, relaxation
etc?
• What kind of job does the patient have? Any
job related exposures are present?

28. • Personal habits: alcohol / tea/ coffee intake, how much? Any
history of vomiting, diarrhea?
• Smoking cigarettes/ using recreational drugs like marijuana,
cocaine, amphetamines etc
• Ever used IV drugs? Has ever swapped needles?
• Ever been exposed to any infectious or sexually transmitted
diseases?

31. Menstrual history
• Information about last menstrual period (LMP)
• Regularity, duration, any contraceptive measures taken, number of
living children, still birth, infertility etc.

32. Social history
• It includes the information about
• Ethnicity
• Language spoken
• Educational status
• Occupation (type of job)
• Housing (owning or renting shelter)
• Type of family
• Family relationship / friendship
• Adequacy of income
• Home and neighborhood conditions

33. Environmental history
• It includes the information about:
• Source of drinking water
• Sanitation status at home and surrounding: type of drainage system,
type of toilet, kitchen style, type of fuel used in cooking etc

34. Travel history
• Traveling increases the risk of unusual or tropical diseases
• For e.g.: malaria, kalazar, etc

35. Psychological data
• Major stressors experienced and the client’s perception of them
• Usual coping pattern for a serious problem or a high level of stress

36. • Communication style:
• ability to verbalize appropriate emotion
• nonverbal communication—such as eye movements,
gestures, use of touch, and posture
• interactions with support persons and
• the congruence of nonverbal behavior and verbal
expression

37. Review of system

40. Procedure of history taking

41. Articles required for history taking
• Patients chart
• Pen / pencil

42. Techniques
• Be dressed neatly and in a culturally acceptable way for the
interview
• Establish rapport with the patient:
• greet the patient warmly
• create a friendly and congenial atmosphere
• make him / her feel secure and free to talk

43. Techniques cont…
• Introduce yourself in a friendly manner
• Maintain privacy. Room should be quiet
• Arrange the seating in such a way that both the patient
and nurse are seated at the same level facing each
other
• Show respect to the patient and his ideas. Call the
patient as per the social system like dai, vai, buwa,
ama

44. Techniques cont…
• Explain the purpose of the interview to the patient.
• Indicate the approximate amount of time required for
the interview
• Observe the patient’s non verbal cues such as anger,
guilt, frustration, anxiety etc. when she / he is talking

45. Techniques cont…
• Make conversation at the level of the patient’s
understanding
• Be an attentive listener
• Maintain eye contact to make the patient feel that you
are listening to him / her
• Do not interrupt him / her in between unless he / she is
moving of the point

46. Techniques cont…
• Use the history taking format to collect the
information.
• Make notes in short sentences and make them brief as
possible
• Keep the data obtained in the interview confidential
and share it with the appropriate health team members
only

47. Any questions???

48. Thank you