Case history taking

Taking a full case history

Done by: Pirniyazova Gùlayim

Objectives

• Define effective history taking
• Describe components of patient history
• Outline patient interviewing techniques
• Identify strategies in obtaining history
• Techniques facilitating History Taking
• Special challenges

What is it?

• Patient interview in systematic way to:
• Recording necessary medical information
• All information must be documented precisely and accurately
• + Classical examination signs

Importance

• Help for reaching diagnosis
• Help in formulation treatment plan
• Evaluate medical progress
• Medico-Legal record
• Availability of information for:
• Research
• Reportable diseases
• Insurance claims

Types of patient interview

• Initial history taking
• Inward daily round: progress of condition, results of investigations, respond to treatment
• Discharge interview: plain at home
• Follow up visit: New symptoms & signs since last visit, drug management
• Field research or screening questionnaire