Post on 30-Oct-2014
Patient-centered Medical History Taking
Trevino A. PakasiDept of Community Medicine
Faculty of Medicine Universitas Indonesia
Objectives
At the end of the session, students will be able:• To take medical history based on the patient’s
needs• To take medical history according to the
standard procedure• To withdraw hypothesis or synthesize
individual health problems based on the medical history taking
Outline of the course
• Introduction lecture• Practicing
What you’ve learned?
• Empathy• Humaniora• Communication skill• Interpersonal relation skill
The patient-centered clinical method. Sumber : Stewart et. Al.(1995)
Disease
Illness
Context
Physical,History, lab
Ideas, expectations,
feelings, effect on function
Person
Problems
Goals
Roles
Finding common ground
Mutual decision
Enhancing the patient-doctor
relationship
Incorporating prevention and
health promotion
Being realistic
Patient presents
cues
Exploring both the disease and illness
experience
Understanding the whole person
Disease
Illness
Medical History
Purpose of history taking:• Understanding of the complain• Understanding the patient’s feeling• Understanding the symptoms or illness when
exists• Hypothesis of problems and possible cause
General Procedure• Verification of the patient’s identity• Reason for visiting the physician• Chief complain of illness when occured• Other related symptoms if any• History of the current problems• Pass medical problems related with the current
problems• Other medical history that might be important• Family medical history• Specific questions
Verification of identity
• Full name• Age or date of birth • Address• Background of the patients: formal education,
working, insurance coverage
Remember to start the conversation by interpersonal touch!
Reason of visiting
• Usually patient’s visit regarding his/her concern of any existing health problems / presence of illness
• Patient’s goal to be healthy• Patient’s goal to reduce risk
Formulation of medical history
• Identity• Chief complain / reason to visit• Other related symptoms • History of the current problems• Pass medical problems• Medical history in the family
Specific question
• For example in pediatrics patient: history of birth, lactation, immunization, growth and development
• For example in obstetrics patient: menarche, monthly cycle
• For example in eldery: daily activity at home• For example in psychiatrics: pre morbid
condition, personality
Specific question in family medicine service
Related with the family:• Family tree• Family cycle• Functioning in the family• Culture and habbits in the family• Housing and environment
Formulation of holistic diagnosis
• Aspect 1: patient’s concerned, knowledge, perceiveness, worries
• Aspect 2: clinical / medical problems – POMR• Aspect 3: internal factors• Aspect 4: external factors• Aspect 5: disability score