Clinical History Taking

History Taking and Clinical Examination Skills for
Healthcare Practitioners module
1
Debs Thomas
Faculty Senior Educator
deborah.thomas@heartofengland.nhs.uk

Intended Learning Outcomes
• Outline why a systematic approach to history
taking is required.
• Discuss how to prepare for taking a patient history.
• Identify the key skills required to initiate and
undertake patient consultations.
• Describe the areas of information that need to be
covered, to gain an accurate history.
• Discuss the term ‘safety netting’ and how it can be
achieved.
• Demonstrate taking a patient history.
2

What is History Taking?
• Asking questions of patients to obtain
information and aid diagnosis.
• Gathering data both objective and subjective
for the purpose of generating differential
diagnoses, evaluating progress following a
specific treatment/procedure and evaluating
change in the patient’s condition or the
impact of a specific disease process.
3
(Kings College London 2013)

4
“Always listen to the patient
they might be telling you the
diagnosis”.
(Sir William Osler 1849 - 1919)

Key Principles of Patient Assessment
• It is estimated that 80% of diagnoses are based
on history taking alone.
• Use a systematic approach.
• Practice infection control techniques.
• Establish a rapport with the patient.
• Ensure the patient is as comfortable as possible.
• Listen to what the patient says.
5
(Scott 2013, Talley and O’Connor 2010, Jevon 2009)

Key Principles of Patient Assessment
• Ensure consent has been gained.
• Maintain privacy and dignity.
• Summarise each stage of the history taking
process.
• Involve the patient in the history taking process.
• Maintain an objective approach.
• Ensure that your documentation (of the
assessment) is clear, accurate and legible.
6(Scott 2013, Talley and O’Connor 2010, Jevon 2009)

Assessment (Consultation) Models
• The use of assessment models is dependant
upon the condition of the patient, e.g. the
ABCDE approach (Styner 1976).
• Systematic, structured and suitable model.
• Inter-professional (i.e. shared understanding
and documentation).
7

Assessment (Consultation) Models
• Transactional Analysis (Berne 1964)
• The Medical Model (Unknown author 1960s)
• Physical, Psychological and Social (Royal College of
General Practitioners 1972)
• Folk Model (Helman 1981)
• The Disease – Illness Model (McWhinney 1984)
• Calgary-Cambridge (Kurtz and Sliverman 1996)
• Narrative-based Medicine (Launer 2002)
8

Calgary-Cambridge Consultation Guide
(Kurtz et al. 2005)
Closing the Session
Explanation and Planning
Physical Examination
Gathering Information
Initiating the Session
9
Providing
structure
Building
relationships

10
•Preparation
•Establish rapport
•Identify the reason for
the consultation

Preparation
• Prepare:
1. Yourself
2. The environment
11
“If in a bad mood or distracted during the
consultation, you can end up making a history
rather than taking a history”.
(Kaufmann 2008)

12
Initiating the Session - The Environment

Establishing rapport
• Initial greeting
• Introductions
• Seeking consent
• Respecting the patient
13

1. Providing false reassurance
2. Giving unwanted advice
3. Using authority
4. Using “why” questions
5. Using professional jargon
6. Using leading or biased questions
7. Talking too much
8. Interrupting or changing the subject
14(Jarvis 2012, Lloyd and Craig 2007)
Common Pitfalls of History Taking

• S
• O
• L
• E
• R
15
Sits square on facing the patient
Maintains open body position
Leans slightly forward
Eye contact is maintained
Relaxed (in an appropriate posture)
(Kaufman 2008)
Positive and Negative Non-verbal Behaviours

Identifying the reason for the consultation
• Open questions:
– Always start with an open ended question and take
the time to listen to the patient’s ‘story’.
• Closed questions:
– Once the patient has completed their narrative to
closed questions which clarify and focus on aspects
can be used.
• Leading questions:
– Questions based on your own assumptions that lead
the patient to the answer you want to hear. These
should not be used at all.
16

Identifying the reason for the consultation
Open questions:
- “How can I help you?”
- “You said you have pain on movement, can you tell me which
movements makes your pain worse?”
Closed questions:
- “Are you still taking the aspirin your GP prescribed?”
- “Is that an accurate summary of your symptoms?”
Leading questions:
- “You are not allergic to anything are you?”
- “Are your joints painful in cold weather?”
17

• The practitioner’s role combines:
– Establishing rapport
– Listening
– Demonstrating empathy
– Facilitating
– Clarifying
NB: this role is performed throughout the whole history taking
and clinical examination process.
18

• The second stage of the Calgary-Cambridge
guide involves the exploration of the patient’s
problem(s), in order to discover:
 Biomedical perspective
 Patient’s perspective
 Background information (the context)
19

20
1. Presenting complaint(s) (PC)
2. History of presenting complaint(s) (HPC):
3. Past/Previous medical history (PMH)
4. Drug history and Allergies
4. Social history (SH)
5. Family history (FH)
6. Systems review
(Jarvis 2012,
Talley and O’Connor 2010)
• Principle complaint
• Details of current complaint
• Effects of complaint on activities of living
• SOCRATES or PQRST
• Past illnesses, hospitalisations, operations • Past treatments
• Occupation, Marital
status, Accommodation, Hobbies, Social life
• Smoking and alcohol consumption
• Diet, Sleeping, General wellbeing,
• Prescribed medication
• Over the counter medication / herbal remedies
• Any side-effects or problems with medication
• Any allergies

Symptom Analysis
• S
• O
• C
• R
• A
• T
• E
• S
21
Site
Onset
Character
Radiation (of pain or discomfort)
Alleviating factors
Timing
Exacerbating factors
Severity (Talley and O’Connor 2010)

Symptom Analysis
• P
• Q
• R
• S
• T
22
Provocative / palliative
Quality
Region / radiation
Severity
Temporal / timing

Patient’s Perspective
• The patient’s perspective of their condition:
– Ideas and beliefs
– Concerns
– Expectations
– Effects on life
– Feelings
23

Systems Review
Central Nervous System / Neurological: Eye:
Endocrine: Cardiovascular:
24
(Douglas et al. 2005)
• Headaches
• Head injury
• Dizziness
• Vertigo
• Sensations
• Fits / faints
• Weakness
• Visual disturbances
• Memory and concentration changes
• Excessive thirst
• Tiredness
• Heat intolerance
• Hair distribution
• Change in appearance of eyes
• Chest pain
• Breathlessness
• Palpitations
• Ankle swelling
• Pain in lower legs when walking
• Visual changes
• Redness
• Weeping
• Itching / irritation
• Discharge

Systems Review
25
Respiratory:
• Shortness of breath
• Cough
• Wheeze
• Sputum
• Colour of sputum
• Blood in sputum
• Pain when breathing
Gastrointestinal:
• Dental / gum problems
• Tongue problems
• Difficulty in swallowing
• Nausea
• Vomiting
• Heartburn
• Colic
• Abdominal pain
• Change of bowel habits
• Colour of stools
Ear, Nose and Throat: (often
incorporated into the Respiratory System
review)
• Earache
• Hearing deficit
• Sore throat

Systems Review
26
Genitourinary system:
• Pain on urination
• Blood in urine
• Sexually transmitted infections
Women:
• Onset of menstruation
• Last menstrual period
• Timing and regularity of periods
• Length of periods
• Type of flow
• Vaginal discharge
• Incontinence
• Pain during sexual intercourse
Men:
• Hesitancy passing urine
• Frequency of micturition
• Incontinence
• Urethral discharge
• Erectile dysfunction
• Change in libido

Systems Review
27
Head to ...
... toe
assessment
Musculoskeletal:
• Joint pain
• Joint stiffness
• Mobility
• Gait
• Falls
• Time of day of pain
Integumentary (Skin):
• General pallor of patient, e.g.
pale, flushed, cyanotic, jaundiced
• Rashes
• Lumps
• Itching
• Bruising

• The practitioner’s role combines:
– Maintaining rapport
– Listening
– Demonstrating empathy
– Facilitating
– Clarifying
– Summarising
28

• The third Calgary-Cambridge stage concerns
physical examination.
• Preparation is key:
– WIPER
– Explanation of the procedure
– Consent sought
– Privacy and dignity maintained
– Chaperone (if required)
29

• The fourth Calgary-Cambridge stage covers
explanation and planning:
30
Providing
information
Aiding recall
and
understanding
Achieving a
shared
understanding
Planning and
shared
decision
making

• Providing the correct amount and type of
information:
– ‘Chunking and checking’.
– Asks the patient what information they require.
• Aiding accurate recall of understanding:
– Uses appropriate language.
– Gives an appropriate explanation.
31

• Achieving a shared understanding:
– Relates explanations to the patient.
– Encourages the patient to contribute.
• Planning, shared decision making:
– Shares own thinking as appropriate.
– Negotiates a plan.
– Checks with the patient about the plan of action.
32

Closing the Session
• The final stage of the Calgary-Cambridge
approach emphasises:
33
•Forward planning
1
•Ensure appropriate
point of closure2

Closing the Session
• Forward planning:
– Discusses the next steps.
– Possible opportunity for health education.
– ‘Safety netting’ covers an explanation of possible
unknown outcomes, what to do if the plan is not
working, when and how to seek help.
34

Closing the Session
• Ensuring appropriate point of closure:
– Summarises consultation briefly (with the
patient), clarifying plan of care.
– Final check that the patient agrees and is comfortable
with the plan, and asks for any corrections, questions
and other items to discuss.
– Include a brief written summary e.g. “This is a 64 year
old smoker, with a 3 month history of central chest
pain related to exercise. He has a 10 year history of
hypertension”.
35

Calgary-Cambridge Consultation Guide
(Kurtz et al. 2005)
Closing the Session
36
Providing
structure
Building
relationships

Summary
• Be systematic in your approach.
• Establish a rapport with the patient.
• Listen to what the patient is saying.
• Clarify and summarise information.
• Provide a ‘safety net’.
• Recognise own boundaries and seek senior
support.
• Escalate and/or refer to the appropriate person.
37

38
“Medicine is learned at the
bedside and not in the
classroom”.
(Sir William Osler 1849 – 1919)

Further Learning Opportunities
• Practice, practice, practice!
• Observe fellow health practitioners
undertaking patient assessments.
• Reflect (on the practice of others and on your
own abilities and experiences).
• See the suggested ‘Key Texts’ in the Module
Handbook.
39

Further Learning Opportunities
On-line:
40
Ambulance
Technician Study
http://www.ambulancetechnicianstudy.co.uk/patassess.html
Critical Care
Practitioner
http://www.criticalcarepractitioner.co.uk
GP-Training http://www.gp-
training.net/training/communication_skills/calgary/cambridge.pdf
University of
Manchester
http://www.medicine.manchester.ac.uk/cbme/tutornotes/calgaryca
mbridgeframework.pdf
Nurse Led Clinics http://www.nurseledclinics.com
Nursing Standard http://www.nursingstandard.co.uk (Subscription only)
Nursing Times http://www.nursingtimes.net (Many articles can be downloaded)
Patient.co.uk http://www.patient.co.uk/

References
• Chafer, A. (2003) Communication Skills Manual. [On-line].
http://www.easterngp.co.uk/pages/resources/documents/resk_Manual0cm0
203.pdf?PHPSESSID=ceadf362cd0b668b4ce9165e3ac1c310 [Accessed 12th
September 2010].
• Douglas, G. Et al. (2005) Macleod’s Clinical Examination. 11th Edition.
Edinburgh; Churchill Livingstone.
• Fawcett, T. Rhynas, S. (2012) Taking an patient history: the role of the nurse.
Nursing Standard. 26, 24, 41-46.
• Fischer, M. Ereaut, G. (2012) When Doctors and Patients Talk: Making Sense of
the Consultation. London; The Health Foundation .
• Jarvis, C. (2012) Physical Examination & Health Assessment. 6th Edition.
St.Louis; Elsevier Saunders.
• Jevon, P. (2009) Clinical Examination Skills. Chichester; John Wiley & Sons Ltd.
• Kaufmann, G. (2008) Patient assessment: effective communication and history
taking. Nursing Standard. 23, 4, 50-56.
41

References
• Kings College London (2013) Introduction to History Taking. [On-line].
http://www.kcl.ac.uk/health/study/facilities/chantler/docs/PatientEducation/H
istoryTakingNOTES.doc [Accessed 10th April 2013].
• Lloyd, H. Craig, S. (2007) A guide to taking a patient history. Nursing Standard.
22, 13, 42-48.
• Moulton, L. (2007) The Naked Consultation: A Practical Guide to Primary Care
Consultation Skills. Abingdon; Radcliffe Press.
• Scott, O. (2013) History Taking and Physical Examination. [On-line].
http://www.patient.co.uk/doctor/History-and-Physical-Examination.htm
[Accessed 2nd May 2013].
• Smith, R. (2003) Thoughts for new medical students at a new medical school.
British Medical Journal. 20, 327 (7429), 1430-1433.
• Talley, N. O’Connor, S. (2010) Clinical Examination: A Systematic Guide to
Physical Diagnosis. 6th Edition. Edinburgh; Churchill Livingstone.
• Walsh, M. (Ed) (2006) Nurse Practitioners: Clinical Skills and Professional Issues.
2nd Edition. Edinburgh; Butterworth Heinemann / Elsevier.
42

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