Case history taking



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Taking a full case history

Done by: Pirniyazova Gùlayim

Objectives

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

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