What is the proper technique for taking a medical history?

Proper Technique for Taking a Medical History

The proper technique for taking a medical history requires establishing rapport with the patient in a comfortable, non-threatening environment, using patient-centered communication to develop partnership, and following a structured approach that includes gathering relevant information about the presenting complaint, past medical history, medications, and psychosocial factors. 1

Creating the Right Environment and Establishing Rapport

• Begin by creating a comfortable environment where the patient feels safe sharing sensitive information 1
• Introduce yourself and explain the purpose of the history-taking session to set expectations 1
• Maintain appropriate body language by orienting yourself toward the patient, especially your lower body, and consider touching the patient appropriately to maintain engagement 1
• Use an informal, conversational style that builds rapport and identifies patient strengths and resources 1
• Consider addressing the patient's occupation early in the conversation as this can help establish rapport and provide context for explanations 2

Confidentiality and Consent

• Explain confidentiality parameters at the beginning of the session, particularly important for adolescents 1
• Obtain appropriate consent, recognizing that confidentiality concerns may prevent patients from seeking or continuing care 1
• Clarify who will have access to the information being shared and under what circumstances confidentiality might be broken (e.g., risk of harm) 1

Structured Approach to History Taking

• Begin with open-ended questions about the presenting complaint, allowing the patient to tell their story in their own words 1
• Follow a systematic approach that includes:
  • Chief complaint and history of present illness 1
  • Past medical history, including previous diagnoses and treatments 1
  • Medication history (current and past medications, allergies, adverse reactions) 1
  • Family history of relevant conditions 1, 3
  • Social history (occupation, living situation, substance use, etc.) 1
  • Review of systems 1

Special Considerations for Different Populations

• For adolescents: Use a developmentally appropriate approach and consider seeing them alone for part of the interview 1
• For elderly patients: Take extra time and be aware they may be at higher risk for medication errors 1
• For patients with cognitive or communication disorders: Include family members or caregivers while still respecting patient autonomy 1

Communication Techniques

• Use motivational interviewing techniques, particularly for sensitive topics or when addressing health behavior change 1
• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment 1
• Avoid medical jargon and adapt your language to the patient's level of understanding 1
• When using electronic health records during the interview:
  • Explain to the patient why you are using the computer 1
  • Share the screen when appropriate to involve the patient 1
  • Verbalize what you are doing on the computer to maintain engagement 1
  • Consider reviewing the patient's record before calling them in 1

Documentation Best Practices

• Document the patient's story in sufficient detail to accurately retell it 1
• Include the patient's own words when documenting symptoms or concerns 1
• When using electronic health records:
  • Use templates and macros appropriately to improve efficiency and completeness 1
  • Avoid copy/paste of entire notes, which can perpetuate errors 1
  • Clearly indicate when information is pulled from another location in the chart 1

Psychosocial Assessment

• Include gentle inquiry about recent stressors or significant life events 1
• Assess the impact of symptoms on daily life, work, and relationships 1
• Be sensitive when exploring trauma history, avoiding repeated questioning if the patient is reluctant to share 1

Common Pitfalls to Avoid

• Rushing through the history and not allowing the patient sufficient time to tell their story 1
• Focusing exclusively on biomedical aspects while ignoring psychosocial factors 1
• Overreliance on templates or electronic health records at the expense of patient engagement 1
• Failing to obtain an accurate medication history, which can lead to prescribing errors 1
• Not explaining the purpose of questions, particularly sensitive ones 1

By following these guidelines, clinicians can obtain comprehensive, accurate medical histories that form the foundation for appropriate diagnosis and treatment while building therapeutic relationships with their patients.