What are the best practices for taking a patient's medical history?

Best Practices for Taking a Patient's Medical History

Begin by establishing rapport in a comfortable environment, then systematically gather information starting with open-ended questions about the chief complaint, followed by structured inquiry into past medical history, medications, family history, social factors, and review of systems—while actively listening and documenting the patient's narrative in their own words. 1, 2, 3

Creating the Right Environment and Establishing Rapport

• Orient yourself physically toward the patient, maintain appropriate eye contact, and explain the purpose of the history-taking session at the outset to establish trust and set clear expectations 3
• Create a safe, non-threatening space where patients feel comfortable sharing sensitive information, particularly important when discussing behavioral health, substance use, or sexual history 1, 3
• Explain confidentiality parameters early in the encounter, especially critical for adolescents and when discussing stigmatized conditions like HIV or psychiatric illness 1, 3

Structured Approach to History Collection

Chief Complaint and History of Present Illness

• Start with an open-ended question such as "What is the main reason you are here today and what would you like to accomplish from this visit?" allowing the patient to tell their story without interruption 1, 3
• The history of present illness is the cornerstone of medical diagnosis and should drive the remainder of your examination and decision-making 1, 2
• Ask patients to provide specific examples when they use vague terms like "memory loss" or "confusion," as their interpretation may differ substantially from clinical definitions 1
• Document symptom onset, duration, character, severity, aggravating and relieving factors, and impact on daily function 1

Past Medical History

• Obtain a thorough health history including cardiovascular disease (myocardial infarction, arrhythmia, heart failure, angina, peripheral artery disease), cerebrovascular disease (stroke, TIA, endarterectomy), and other surgeries with attention to any cognitive difficulties that arose post-operatively 1
• Document chronic conditions including hypertension, hyperlipidemia, diabetes, renal disease, liver disease, lung disease, dementia, depression, autoimmune diseases, and malignancies with dates of diagnosis 1, 2
• Record history of infectious diseases including tuberculosis exposure with tuberculin skin test results, sexually transmitted diseases, and chronic infections 1
• For HIV-infected patients specifically, document the date of HIV diagnosis, approximate date of infection when determinable, all prior antiretroviral regimens with responses (CD4 counts, viral loads), duration of treatment, reasons for changes, drug toxicities, adherence patterns, and prior resistance test results 1
• Inquire about travel and residence history, as patients from endemic areas (Ohio/Mississippi River valleys for histoplasmosis, southwestern deserts for coccidioidomycosis) remain at risk for reactivation disease even after relocation 1

Medication History

• Compile a complete list of all medications including prescription drugs, over-the-counter preparations, methadone, and dietary or herbal supplements, as many interact with prescription medications 1
• Document allergies and hypersensitivity reactions to prior therapies, including specific reactions to sulfonamides, nonnucleoside reverse-transcriptase inhibitors, and abacavir in HIV patients 1
• Before discontinuing any medication, obtain the complete history of previous psychiatric symptoms and response to medication through patient interview, family discussion, medical records review, and consultation with previous prescribers 1

Family History

• Obtain history of diseases in first-degree relatives including strokes, vascular disease (myocardial infarction), dementia, and other neurological diseases 1
• Record age at death for all deceased first-degree relatives and age at which significant events (stroke, dementia onset) occurred 1

Social History

• Document tobacco, alcohol, heroin, and recreational drug use including marijuana, cocaine, and MDMA ("ecstasy") 1
• Record occupation, years of education, literacy level, primary language, living situation, level of independence, type of residence, and marital status 1
• Assess environmental exposures including second-hand smoke, pesticides, and occupational hazards 1
• For women, document menopause status and contraceptive use 1

Review of Systems

• Record subjective symptoms and their onset including cognitive and behavioral symptoms, gait problems, tremor, balance difficulties, swallowing problems, incontinence, and pseudobulbar affect 1
• For patients with suspected cognitive impairment, document symptoms affecting memory, language, visuospatial function, executive function, and behavior 1

Critical Communication Techniques

Active Listening and Patient Engagement

• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment throughout the encounter 3
• Allow patients sufficient time to tell their story without rushing—the likelihood of disagreement between patient and informant perspectives can provide valuable diagnostic clues 1
• Use motivational interviewing techniques particularly for sensitive topics or when addressing health behavior change 3

Use of Informants

• When evaluating patients with suspected cognitive impairment, actively seek an informant (family member or close friend) as they provide added value beyond patient self-report and cognitive test performance 1
• Document the informant's relationship to the patient, length of relationship, amount and type of contact, and their own demographic information (birthdate, gender, ethnicity, education, living status relative to patient) 1
• Consider interviewing patient and informant separately if there is discomfort with honest reporting or overt friction, as this may reveal important diagnostic information 1
• Acknowledge upfront that disagreement between patient and informant is common and helpful: "This is a safe place where you should feel free to disagree with each other—it helps me understand better" 1

Documentation Best Practices

• Document the patient's narrative in sufficient detail to accurately retell their story, including the patient's own words when describing symptoms or concerns 2, 3
• Record proper patient identification including surname, forename, date of birth, and hospital unique identification number 2
• Use macros and templates appropriately to improve completeness and efficiency for standardized elements like review of systems, but avoid "copy/paste" of entire notes without editing as this propagates factual errors and outdated information 2
• Document vital signs including height, weight, blood pressure (including orthostatic measurements), waist circumference, ankle-brachial index, heart rate, respiratory rate, temperature, vision, and hearing 1

Special Population Considerations

Elderly Patients

• Take extra time with elderly patients who are at higher risk for medication errors and may have multiple comorbidities 3
• Recognize that oxygenation is reduced in the supine position, so allow fully conscious hypoxaemic elderly patients to maintain the most upright or comfortable posture possible 1

Adolescents

• Use developmentally appropriate approaches and consider seeing adolescents alone for part of the interview 3
• Explain confidentiality parameters clearly at the beginning, as this is particularly important for adolescent engagement 3

Patients with Cognitive Impairment

• Recognize that diminished insight is common in cognitive-behavioral syndromes, so patient and care partner may have divergent opinions about symptoms—this divergence itself is diagnostically valuable 1
• Be flexible and pursue all lines of the story, integrating perspectives from multiple sources including post-visit phone calls when needed 1

Common Pitfalls to Avoid

• Never rush through the history or fail to allow sufficient time for the patient to tell their story 3
• Avoid focusing exclusively on biomedical aspects while ignoring psychosocial factors that may be driving or exacerbating illness 3
• Do not over-rely on templates or electronic health records at the expense of direct patient engagement 3
• Never discontinue oxygen therapy to obtain an oximetry measurement on room air in patients who clearly require oxygen 1
• Avoid making assumptions about what patients mean by common terms—always ask for specific examples and clarification 1

When to Seek Additional Information or Specialist Consultation

• Obtain medical records from previous healthcare providers whenever possible, especially for patients with complex medication histories or prior treatment failures 1
• Consider specialist referral for young patients with lifelong difficulties, patients with trauma history, those with abnormalities found on examination, or when initial screening tests indicate important abnormalities 1
• Be prepared to call for expert assistance early when patients have major life-threatening illnesses, including 999 ambulance in prehospital care or resuscitation/ICU outreach teams in hospital settings 1