03.01.01. Patient history
Relevant patient history is obtained, reviewed and considered before an exam, procedure or treatment
Importance of patient history
- The information gathered for a patient history varies according to the exam/procedure or stage within the treatment process.
- Patient history influences how the procedure is performed and how pre-treatment planning proceeds1-3.
- Patient history assists with the interpretation of the results/outcomes1-3.
Gathering a patient history
- Patient history can be gathered from a medical record or the patient and/or caregiver.
- The environment influences the history-taking process and how complete and informative the answers will be4.
- The way information is gathered also affects the quality of the patient history1-5:
- Find a private area to have discussions of a confidential nature
- Explain to the patient and/or caregiver why this information is required and reassure them that information will only be shared with those involved in his/her medical care
- Ensure the questions asked are worded to get the information you need, rephrase questions or ask follow-up questions if necessary
- Listen to the patient’s answers and allow them to guide the interview and identify further investigation4
- Before proceeding confirm the patient has addressed all questions and concerns he/she feels might be important for the healthcare team to know for this procedure/treatment
- If the history has been taken by someone else, it is important to review and clarify pertinent information.
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References
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Torres LS, Guillen Dutton A, Linn-Watson T. Patient Care in Imaging Technology. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins. 2010.
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Adler AM, Carlton RR. Introduction to radiologic sciences and patient care. 3rd ed. St. Louis, MO: Saunders; 2003.
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Tierney LM Jr., Henderson MC, eds. The Patient History: Evidence-based Approach. McGraw-Hill Companies, Inc.; 2005.
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Malcolm HA. Does Privacy Matter? Former patients discuss their perceptions of privacy in shared hospital rooms. Nurs Ethics 2005;12(2):156-166.
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Lin YK, Lin CJ. Factors predicting patients’ perception of privacy and satisfaction for emergency care. Emerg Med J. DOI: 10.1136/emj.2010.093807.