Patient History - Repetition Helps

management Apr 05, 2021
get a good patient history

One of my favorite attendings in residency, Dr. Asimos, would take each of us into a room with him and listen as we interviewed and examined a patient. Then we would go into another room with him as he did a patient history. His approach was the same with every patient, regardless of the complaint. When you have the same approach every time, you are less likely to forget, more apt to remember details, and don't even need to write things down after perfecting it. 

Ask patient name, introduce yourself. Before asking why they are here, follow this routine...

Who is your doctor? This gives insight as to whether or not they have someone to in fact follow up with or if there may be barriers to healthcare access. If not, you already know they may need to return to the ER if there are any problems.

What medical problems/surgeries do you have or have had? This will give you valuable information regarding potential complications, risk for poorly healing wounds, infection. Paying close attention to DM, vascular disease, renal disease, chronic steroid use, immunocompromised state.

What medications do you take? It is inevitable that they say they have no medical problems but have 10 pill bottles with them. This can serve as a check to find out if they really do have medical problems. Certain medications, like steroids, which may cause thin skin and impair wound healing.

Do you have any allergies to medications? This may influence prescribing if antibiotics are to be given.

Do you smoke, drink, do any drugs? Smoking is a risk factor for poorly healing wounds, you will need to address this and may influence decision to close the wound primarily

Ok, tell my why you are here today...

 

So, in less than a minute (usually), I already know this patient quite well. I have in my mind a framework on how my medical decision making will look and even my discharge instructions. Of course, I have to look at the wound and repair it, but it is helpful to go ahead and have this information upfront, in my mind before I repair the wound, chart in the EMR, etc... It also may give me a few things to talk about when I am at the bedside and repairing the wound. 

I have found this approach to be very helpful whether working in the ED or urgent care. I can go see a few patients at one time and keep them straight. I can go back and get more information or review the EMR if needed. I encourage you to develop a consistent strategy when it comes to interviewing patients, it makes a big difference. 

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