Appendix 1: History Taking Framework Introduction to History Taking Aims



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APPENDIX 1: History Taking Framework

Introduction to History Taking

Aims:

To develop interviewing and data gathering skills in preparation for Year 3.

To include:


  • A clear structured approach, which emphasises the importance of communication skills when interviewing patients

  • A KCL History Taking format which can be learnt across the school and used in Year 3, 4 and 5.

Framework to History Taking

General Procedure

Eliciting a history from a patient is an essential part of being an effective doctor. It:



Ineffective communication is the most common reason for complaints against doctors. The majority of malpractice allegations arise from communication errors.

Interviewing the patient in private, introducing yourself, helps building a relationship with the patient and explaining the purpose for the interview with approximate time needed.

Taking a history is not just going down a checklist of symptoms. Books have been written about how to consult with patients and there is no set “right way”. Eliciting a patient’s history does not need to be done in a set order. You may have observed doctors who adapt their questioning so that it naturally follows the conversation they are having with the patient. At the end of the interview the doctor can mentally check that all aspects of the history have been covered before structuring the history into the traditional medical model.

It is not just information-gathering from the patient, it is a two way communication in which you need to be aware of what and how you are communication and its impact on the patient.

It does include active listening to the patient, awareness of non-verbal communication, with respect and support of their feelings.

It is important to use your communication skills effectively, in order to data gather and reach a diagnosis, so that you may decide with the patient the appropriate management. Use the communication skills you have learnt and practised, and your own experience when talking with people.






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