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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