Chapter 12 History Taking PDF

Chapter 12 History Taking 1 Objectives (1 of 2) ˜ ˜ ˜ Describe the role of the radiologic and imaging sciences professional in taking a clinical history. Describe the desirable qualities of a good patient interviewer. Differentiate objective from subjective data. 2 Objectives (2 of 2) ˜ ˜ ˜ Explain...

Chapter 12 History Taking 1 Objectives (1 of 2) ˜ ˜ ˜ Describe the role of the radiologic and imaging sciences professional in taking a clinical history. Describe the desirable qualities of a good patient interviewer. Differentiate objective from subjective data. 2 Objectives (2 of 2) ˜ ˜ ˜ Explain the value of each of the six categories of questions useful in obtaining clinical histories. Describe the importance of clarifying the chief complaint. Detail the important elements of each of the sacred seven elements of the clinical history. 3 Patient History Process (1 of 2) ˜ ˜ ˜ ˜ Look at taking a patient history as an interview of the patient. In most cases, the radiologist seldom has the opportunity to meet the patient. Often, the radiologic and imaging sciences professional is the eyes, ears, and voice of the radiologist. Possessing good history-taking skills is an essential responsibility of the radiologic and imaging sciences professional. 4 Patient History Process (2 of 2) ˜ ˜ ˜ Information gathered needs to be accurate and specific in detail, if possible. History needs to include relevant information to examination. Genuine interest in what the patient has to say, attentiveness, and an image of professional competence can provide patients with a real sense of caring. 5 Qualities of Interviewer (1 of 2) ˜ ˜ ˜ ˜ ˜ Acknowledge patient’s anger, if present. Respect patient. Be genuine. Empathize (not sympathize) with patient’s condition. Patients need to feel the information they are providing, is important. 6 Qualities of Interviewer (2 of 2) ˜ ˜ ˜ ˜ ˜ ˜ Don’t intimidate patients. Be attentive to detail. Demonstrate accurate note-taking skills. Have good questioning skills. Develop multitasking, communication skills. Maintain a polite and professional demeanor. 7 Data Collection Process (1 of 2) ˜ ˜ ˜ ˜ 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. Data collected needs to be documented precisely and clearly, using appropriate medical language. 8 Data Collection Process (2 of 2) Objective data Ø Ø Ø Ø Perceptible to senses Able to be measured Often physiologic Signs that can be seen, heard, felt, etc. Subjective data Ø Ø Ø Ø Ø Patient feelings Pain level Attitude Opinion of observer Subject to interpretation Objective data is no more important than subjective data. 9 Questioning Skills ˜ ˜ ˜ ˜ ˜ ˜ ˜ Use open-ended questions. Avoid leading 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 information collected. Summarize to verify accuracy. 10 What do radiologists want to know about the patient history? The patient’s chief complaint! 11 If you have to ask just one basic question when taking a history, ask the following: Why is this examination being done? Or Do you know why your doctor ordered this procedure? 12 Elements of the Clinical History ˜ Chief complaint Ø MDs tend to focus on this. Ø Permit the patient to add more than a single complaint when it appears multiple complaints are valid. Ø Ignoring all symptoms except the most predominant can cause you to miss other important clinical information. 13 Sacred Seven of Medical Histories ˜ Localization Ø ˜ ˜ ˜ ˜ ˜ ˜ Localized vs. non-localized Chronology Quality Severity Onset Aggravating or alleviating factors Associated manifestations 14 Patient History Considerations ˜ ˜ ˜ ˜ Does patient history data match requisition? Do symptoms support exam? Verify symptoms with exam request. How would you describe pain? Localized versus general Where How long Duration Ø Old versus new Ø Ø Ø Ø 15 Role of Technologist ˜ ˜ ˜ ˜ ˜ ˜ Act as a good listener. Take accurate notes and record them appropriately. Get answers to key clinical questions. Present a professional image. Play important role in interacting with patient. Become a patient advocate.* * In certain instances, the radiologic and imaging sciences professional may need to clarify an inconsistency between a patient’s medical history and the type of medical procedure ordered by their physician. This often requires a direct communication with the ordering practitioner and a radiologist. 16 Conclusion (1 of 2) ˜ ˜ ˜ ˜ ˜ Consider the patient history as an interview with the patient. A complete medical history includes both objective and subjective data. 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. 17 Conclusion (2 of 2) ˜ ˜ ˜ ˜ ˜ Look for objective and subjective data. Present a professional image. Take accurate notes with attention to detail. Never forget, you often are the eyes, ears, and voice of the radiologist with the patient. Your observations and assessment are essential to helping the radiologist. 18