A Guide to History Taking
A Guide to History Taking
Objectives
By the end of these revision notes, you should:
Why is History Taking important?
History taking forms the foundation of any clinical consultation. By understanding how to take a good history, you can maximise your productivity in appointments and manage patient concerns more effectively. A comprehensive and structured history taking will allow for quicker diagnosis and appropriate treatment planning.
History taking also requires you to communicate effectively with your patients and this helps to build rapport. Additionally, if you are liaising with colleagues or other healthcare professionals then having a good history is important for case discussion. Below we cover the various aspects of systematic history taking.
Introduction
A basic introduction to the patient as to who you are and your role. This is also the moment you gain consent from the patient to begin a consultation and start with an open question such as ‘How can I help you today?’ or ‘I understand you’re having some problems, am I okay to ask you about these?’.
Presenting Complaint (PC) and History of Presenting Complaint (HPC)
This is where we want to learn more about what is concerning the patient in their own words, e.g. ‘My bottom tooth hurts’. Depending on their complaint, we would then want to ask appropriate questions to explore further. One of the best ways, in most situations, is to use the acronym SOCRATES.
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Past Medical History (PMH)
Drug History (DH)
Past Dental History (PDH)
Family History (FH)
Social History (SH)
Summarise the History
Summary