Transcript The History
PARAMEDIC CARE: PRINCIPLES & PRACTICE Patient Assessment The History The ability to elicit a good history lays the foundation for good patient care. Topics History Taking Techniques Active Listening The Comprehensive Health History Patient Rapport Setting the Stage If a patient’s chart is available, review it before interviewing the patient. Use this information to gain clues about the patient. The First Impression Present yourself as a caring, competent, and confident health care professional. When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build trust. Asking Questions Use a combination of openended and close-ended questions. Language and Communication Use appropriate language. Use an appropriate level of questioning, but do not appear condescending. When encountering communication barriers, try to enlist someone to help. Actively listen. Active Listening Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. It is important to earn a patient’s trust. The Comprehensive Patient History Elements of the Patient History Preliminary Data Date and time Age Sex Race Birthplace Occupation The Chief Complaint This is the pain, discomfort, dysfunction that caused the patient to request help. The Present Illness OPQRST-ASPN Onset of the problem Provocative/ Palliative factors Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives Past History General state of health Childhood diseases Adult diseases Psychiatric illnesses Accidents or injuries Surgeries or hospitalizations Current Health Status (1 of 3) Current medications Allergies Tobacco Alcohol, drugs, and related substances Diet Screening tests Immunizations Current Health Status (2 of 3) Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and significant others Daily life Current Health Status (3 of 3) Important exercises Religious beliefs The patient’s outlook You should take your patient’s medications with you to the hospital, when practical. Review of Systems A system-by-system series of questions designed to identify problems your patient has not already identified. Special Challenges (1 of 2) Silence Overly talkative patients Multiple symptoms Anxiety Depression Sexually attractive or seductive patients Confusing behaviors or symptoms Special Challenges (2 of 2) Patients needing reassurance Anger and hostility Intoxication Crying Limited intelligence Language Barriers Hearing problems Blindness Talking with families or friends If the patient cannot provide useful information, gather it from family or bystanders. Summary History taking techniques Active listening The comprehensive health history