History Taking Pharmacy 1213

7/30/2019 History Taking Pharmacy 1213

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STRUCTURED HISTORY,

DOCUMENTATION AND

DECISION SUPPORTTECHNOLOGY

Matthew Catterall


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Teaching Aim & Learning

Outcomes

Aim

To gain a working knowledge of structured historycollection from a patient, its documentation anduse of decision support technology

Learning Outcomes

Explore communication strategies

Describe and discuss the stages in the medicalmodel of assessment

Appreciate methods for documenting anassessment


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Practical Use of a Structured

History


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s ory ocumen a on s oudemonstrate the following

elements SUBJECTIVE What you find out from the patient/relatives/carers

OBJECTIVE

What you find out from your examinationmeasurable and repeatable

ASSESSMENT / ANALYSIS

Putting together the information you have gained,what do you think is going on?

PLAN

What are you going to do about it?Prescribe/Advise/Refer


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Health History

A thorough, accurate & systematic review

Explores past & present problems

Can lead to a diagnosis which can then be

confirmed or rejected by an examination of the

patient

The history gives you subjective data from

which to work


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Medical History

PC Presenting Complaint HPC History of Presenting Complaint PMH/PSH Previous medical/surgical history

DH Drug History SH Social History FH Family History ROS review of systems

O/E On Examination (focussed systemsexam)Assessment/Analysis Plan


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Presenting Complaint

Presenting complaint

A short description of the reason for seeking care

Based on what the patient tells you

E.g Faint, Left Ankle Injury, Feeling tired, Chestpain

History of the presenting complaint

The nature of the problem

How and when it started How it has progressed over time

Impact on the patient

Work, exercise, social activities


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HPC Example

2/7 ago playing football at 1100

Fell inverting left ankle whilst running for ball

Able to play on for 1/24

Becoming progessively more painful despite

analgesia

Today pain ++ with inability to weight bear

Unable to drive to work

Driven to hospital by wife


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Previous Medical/Surgical

History

Previous medical history

E.g Asthma, COPD, IBS

Previous surgical history (date)

E.g Hysterectomy (2003), CABG (2007)

Current management

Effectiveness

Prognosis


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Drug History

Drug, dose, route, frequency

Prescribed medication

Over the counter medication

Herbal remedies

Illicit, street or recreational drugs

Allergies/ senstivities/ intolerance


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Social History

Occupation/sAlcohol (ETOH) units/week

Men 21 Women 14

Smoking (cigarettes/day)Actvities of Daily Living (ADLs)Any formal/informal care Relatives, family, friends etcAccomodation

Mobility aids Hobbies Recent travel


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Family History

Current family make up

Grandparents, parents, siblings

Causes of death where relavant

Diagnosed diseases


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Review of systems (RoS)

Functional enquiry

Tailored to the presenting complaint

Record pertinent negatives as well as

positives

Includes all major systems


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Look for evidence of....

Respiratory System (RS)

Cough, Sputum, Haemoptysis, Shortness ofbreath (SOB), Wheeze

Cardiovascular (CVS) Chest pain (at rest or on exertion), Palpitations,

Shortness of breath, Odemea, Orthopnea

Gastrointestinal (GI)

Indigestion, Abdominal pain, Nausea, Vomiting,Change in bowel habit, Unintentional weight loss,

Appetite, Diarrhoea, PR bleed, Dysphagia


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Look for evidence of.... Cont

Genitoruninary (GU)

Urgency, Frequency, Polyuria, Dysuria,

Haematuria, Nocturia, Menstrual problems

(Pregnancy ?)Neurological (NS)

Faints, fits & funny turns, Loss ofconsciousness, Headache, Visual disturbances,

Dizziness or vertigo, Tingling, Incontinence,Rash, Photophobia

Musculoskeletal (MS)

Aches, Pains, Stiffness


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Documentationthe patient

has been

depressed

since he

started

seeing me

in 1983

she slipped

on the iceand her legs

wen

separate

ways in

early

December

the patient

was to have a

bowelresection.

However he

took a job as

stockbroker

instead


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Documentation

Concise Relevant Legible

Legal document & part of patients medical record

NOT DOCUMENTED = NOT DONE!!

Remember your notes may need to be defendedin court

Use ink, write legibly, use abbreviations carefully,dont write humorous comments - record factualinformation only

Include contextual information Date & Time (24 Hour Clock), Location, Your Details,

Patient Information (Name, Age, Gender, Occupation)


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On Examination (O/E)

Record an initial impression Pt sitting in chair, not distressed, responding appropriately.

Mother present during examination

Examine appropriate system/s

Consider limitations without chaperoneDuring your assessment analyse the following factors

Likely explanation for the presentation

Is the patient

Comfortable or distressed Well or ill

Well nourished/hydrated

Exhibiting classical signs (syndromes)


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Documenting System

Examinations

Respiratory System (RS)Nervous System (NS)

Abdomen (Abdo, GI, GU)


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Diagnosis & Treatment

Planning

Final diagnosis

Synthesis of history and examination

Not always clear

Impression often suffices inurgent/emergency care

Working diagnosis may be required

Enables early treatment of urgentproblems

Differenetial Diagnosis (DDx)

Dictates treatment Range of potential diagnoses

Ruled in or out by investigations

Demonstrates consideration of red flagpresentations

Tailored to patient

Specific instructions for

interventions Advice to patient

Discharge instructions

Referral

Follow up care Safety Net advice

999 if chest pain, GPreview if not resolving etc

Diagnosis (Dx) Treatment Plan (Rx)


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Decision Support Technology


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Example Algorithm


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Any questions?


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References

Bickley, L. (2003). Bates' guide to physicalexamination and history taking. Philadelphia:Lippincott, Williams and Wilkins.

Douglas, G., Nicol, F. & Robertson, C. (2009).Macleods clinical examination. (12th ed.).Edinburgh: Churchill Livingstone Elsevier.

Wardrope, J., Driscoll, P., Laird, C. & Woollard,W. (2008). Community emergency medicine.Edinburgh: Churchill Livingstone Elsevier.

This presentation has been sourced from theabove texts however there are many texts whichrefer to the same information.

History Taking Pharmacy 1213

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