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Copy of Copy of History Taking

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Eva Flynn

on 19 January 2015

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Transcript of Copy of Copy of History Taking

Communication Skills
Dr. Eva Flynn

Review of last week...
What is the purpose of History Taking?

Information gathering
Why is this important to you as a prescriber?
To identify 'problems'
To explore the health/illness of the patient
To plan for the next step...
Diagnosis depends on three main areas:
Taking a history
Physical examination
Investigative tests

83 % doctors made correct diagnosis on the basis of medical history only (Hampton et al 1975)
76% correct diagnosis after taking a clinical history only (Peterson et al 1992)

Why are we learning this...
Good communication skills
Identify patients ‘real’ agenda
Patient satisfaction
Improved health outcomes
Basic communication skills
Avoid interruptions
Open questions
Non-verbal communication
Non medical terminology
Any disparity between verbal and non verbal

Set the Agenda
Use open-ended questions initially.. funnel
Negotiate a list of all issues - Agenda Setting
Presenting complaint(s) and other concerns
Specific requests (i.e. medication refills)
Clarify the patient's expectations for this visit - ask the patient "Why now?"
Why do you think the use of a history taking structure important to you in everday life?

Over to you...
Your parents are just home from holiday and you have crashed the car while they were away. Explain!!
Utilising a structured interview process, Calgary-Cambridge Model:
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session

Kurtz S, Silverman J, Benson J, Draper J (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine;78(8):802-809
Initiating the session
Gathering information
Physical Examination
Explanation and planning
Closing the session
Establishing initial rapport
Identifying reason(s) for consultation
Exploration of the patients problems to discover:
Context of problem
Patient's perspective
Background information
Biomedical perspective
Providing the correct amount and type of information, chunk and check
Aiding accurate recall and understanding
Achieving a shared understanding
Planning: shared decision making
Ensuring appropriate point of closure
Forward planning
Providing Structure..
Building the relationship...
Making organisation overt
Attending to flow
Using appropriate non-verbal behaviour
Developing rapport
Involving the patient
The Consultation
Achieve a shared understanding
Patient centred
Non medical terminology
Check understanding
Pick up on non verbal cues
Elicit patient's I.C.E., feelings, reactions
Encourage the patient to contribute
Closing the session
Summarise briefly
Check the patient's understanding again
Contract with the patient about the next steps... signpost...forward plan!
Doctor's agenda
Patient's agenda

Collaborative agenda
Full transcript