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Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics History-Taking Techniques Active Listening The Comprehensive Health History
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Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Division 2Patient Assessment
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 10 History Taking
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
History-Taking TechniquesActive ListeningThe Comprehensive Health History
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Components of a Patient History
Establishing rapportChief complaintHistory of the present illnessPast medical historyCurrent health status– Family history– Psychosocial history
Review of systems
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Interview
Differential field diagnosisHelps establish a bond
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport – The First Impression
Present yourself as a caring, competent, and confident health care professional.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –Building Trust
When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build trust.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport – Asking Questions
Use a combination of open-ended and closed-ended questions.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport – 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.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport – Sensitive Topics
A paramedic must learn to become comfortable dealing with sensitive topics.It is important to earn a patient’s trust.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Comprehensive Patient History
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Preliminary Data
Date and timeAgeSexRaceBirthplaceOccupation
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Chief Complaint
This is the pain, discomfort, and/or dysfunction that caused the patient to request help.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Present Illness OPQRST-ASPN
Onset of the problemProvocative/ Palliative factorsQualityRegion/Radiation
SeverityTimeAssociated SymptomsPertinent Negatives
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Past History
General state of healthChildhood diseasesAdult diseasesPsychiatric illnessesAccidents or injuriesSurgeries or hospitalizations
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Current Health Status (1 of 2)
Current medicationsAllergiesTobaccoAlcohol, drugs, and related substancesDietScreening testsImmunizations
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Current Health Status (2 of 2)
Sleep patternsExercise and leisure activitiesEnvironmental hazardsUse of safety measuresFamily historyHome situation and significant othersDaily life
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
You should take your patient’s medications with you to the hospital,
when practical.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Review of SystemsA system-by-system series of questions designed to identify problems your patient has not already identified:– Skin– Head– Eyes– Ears– Nose– Mouth/Throat– Respiratory– Cardiovascular
– Gastrointestinal– Genitourinary– Musculoskeletal– Neurologic– Psychologic– Endocrine– Hematologic
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Psychosocial HistoryChronic health conditionsJob– Work schedule– Stress
Family dynamicsSupportSafety issues – Car seat usage– Smoke and CO alarms
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Challenges (1 of 2)
SilenceOverly talkative patientsMultiple symptomsAnxiety
DepressionSexually attractive or seductive patientsConfusing behaviors or symptoms
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Challenges (2 of 2)
Patients needing reassuranceAnger and hostilityIntoxicationCrying
Limited intelligenceLanguage barriersHearing problemsBlindnessTalking with families or friends
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the patient cannot provide useful information, gather it from family
or bystanders.
Bledsoe et al., Essentials of Paramedic Care: Division 1I© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
History-Taking TechniquesActive ListeningThe Comprehensive Health History