The Patient History
The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. Each type of history includes some or all of the following elements:
The Patient History
Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors. The extent of history of present illness, review of systems, and past, family and/or social historythat is obtained and documented is dependent upon clinical judgment and the nature of thepresenting problem(s).
The chart below shows the progression of the elements required for each type of history. Toqualify for a given type of history, all three elements in the history table must be met. A chiefcomplaint is indicated at all levels.
The content of the history required in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history. However the general framework for history taking is as follows[1]:
The basis of a true history is good communication between doctor and patient. The patient may not be looking for a diagnosis when giving their history and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified.
It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks. A good history is one which reveals the patient's ideas, concerns and expectations as well as any accompanying diagnosis. The doctor's agenda, incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good history taking. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.
Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations.
To obtain a true, representative account of what is troubling a patient and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patient and doctor. A consultation can allow a patient to unburden himself or herself. They may be upset about their condition or with the frustrations of life and it is important to allow patients to give vent to these feelings. The importance of the lament and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent paper[5].
The skills required to obtain the patient's true story can be learned and go beyond knowing what questions to ask. Indeed 'questions' may need to be avoided, as they limit the patient to 'answers'. There is a lot written about consultation skills and different models of consulting. These have been developed through consultation analysis and now form an important part of undergraduate medical training and GP training in the Curriculum for Speciality Training for General Practice. There are many examples of aspects of consulting which may assist history taking for doctors working with patients in all specialties.
These are seen as the gold standard of historical inquiry. They do not suggest a 'right' answer to the patient and give them a chance to express what is on their mind. Your question should not be able to be answered with 'yes' or 'no'. A broad example is: 'What's been bothering you?' There are other similar open questions but it may be effective just to let the patient start speaking sometimes.
Open questions can be used to obtain specific information about a particular symptom as well. For example: 'Tell me about your cough.' Or: 'How are your waterworks bothering you?' Open questions cannot always be used, as sometimes you will need to delve deeper and obtain discriminating features about which the patient would not be aware. However, they should be kept foremost in the mind as a way to broach a subject or an unexplored symptom.
Sometimes it is necessary to 'pin down' exactly what a patient means by a particular statement. In this case, if the information you are after cannot be obtained through open questioning then give the patient some options to indicate what information you need. For instance, if a male patient complains of 'passing blood' and it is difficult to tell what he means, even after being given a chance to expand on the subject, you could ask: 'Is that in your water or your motions?' This technique must be used with care as there is a danger of getting the answer you wanted rather than what the patient meant (he might be having nosebleeds). Try to avoid using specific medical terms such as 'coffee grounds' (one of the options you might give if trying to find out if a patient is vomiting blood). If you can use an open question such as: 'What colour was the vomit?', rather than suggesting options, it is more likely to give you a true picture of what the patient has experienced; however, sometimes questions suggesting possible answers cannot be avoided.
These are best avoided if at all possible. They tend to lead the patient down an avenue that is framed by your own assumptions. For instance, a male patient presents with episodic chest pain. You know he is a smoker and overweight so you start asking questions that would help you to decide if it's angina. So you ask: 'Is it worse when you're walking?'; 'Is it worse in cold or windy weather?' The patient is not sure of the answer, not having thought of the influence of exercise or the weather on his pain, but answers yes, remembering a cold day when walking the dog when the pain was bad. You may be off on the wrong track and find it hard to get back from there. It is much better to ask an open question such as: 'Have you noticed anything that makes your pain worse?' When the patient answers: 'Pork pies', you are on firmer ground in suspecting that this may be chest pain of gastrointestinal origin.
After taking the history, it's useful to give the patient a run-down of what they've told you as you understand it. For example: 'So, Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing - particularly meat - and the whole thing's been getting you down. Is that right?' If there is a nod of approval or expressed agreement with the story then it's fairly certain you're getting what the patient wanted to tell you. If not, then you may need to try another approach. This technique can avoid incorrect assumptions by the doctor.
It's always a good idea to ask the patient if there's anything they want to ask you at the end of a consultation. This can help you to impart further information if there's something they haven't understood and it can reveal something that's been troubling them that hasn't been touched upon or got to the bottom of. It is an opportunity to confirm that a shared understanding has been reached between doctor and patient.
Wild D, Nawaz H, Ullah S, et al; Teaching residents to put patients first: creation and evaluation of a comprehensive curriculum in patient-centered communication. BMC Med Educ. 2018 Nov 1918(1):266. doi: 10.1186/s12909-018-1371-3.
It is helpful if a clinician is situated so that his/her eyes are at the level of the patient's eyes. For example, if the patient is seated, the clinician should also be seated. It is beneficial if the interview between clinician and patient does not occur in a dental chair as this will not facilitate confidence. In this way, key aspects of the patient's personality, expectations, and medical conditions are more likely to be shared. It is vital that the patient's chief complaint be identified to be later matched with his treatment expectations. All patient interview procedures should ensure patient privacy.
In addition, one should inquire about a history of travel to tropical countries (latency of certain diseases). It may be necessary to procure medical reports if available. In case of doubt consider referring patient to the house doctor or internist for further evaluation or recommendations.
Reviewing the medications that the patient is currently taking, or has taken in the past, may identify risks to surgical and prosthetic treatment. Furthermore, a patient may not always know the conditions for which they are being treated and their medication list may signal additional conditions of concern to be investigated by the clinician. For example, elderly patients consider medication a routine and might forget to mention them, if asked in a generic way. In case of doubt ask patients if they take any medication for the bone, for the heart and so on.
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A medical history is a report that includes information gained from a patient's medically relevant recollections (e.g., symptoms, concerns, past diseases) and questioning regarding their concerns. While a physician should generally take their time to take a thorough history, situations such as medical emergencies may only provide enough time for a short history to avoid delaying potentially vital interventions. Because it takes some practice to distinguish between important and irrelevant information, it is best to follow a set protocol in the beginning. Medical history provides the basis on which diagnosis and treatment are developed. An uninterrupted setting in a quiet room with only the examiner and the patient present ensures that patients can openly discuss their concerns and reinforces the patient-physician relationship. This article provides an overview of what a general medical history should cover. Depending on the patient's concerns, additional and/or more targeted questions may be appropriate. See the articles \u201CPediatrics: history and physical examination\u201D and \u201COB/GYN: history and physical examination\u201D for further details about those patient groups. 041b061a72