Professional Practice in Paramedic, Emergency and Urgent Care

Valerie Nixon

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780470656150
• eBook ISBN: 9781118488225
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing Skills

Professional Practice in Paramedic, Emergency and Urgent Care explores a range of contemporary relevant topics fundamental to professional practice. Written for both pre- and post-registration paramedic students, it is also ideal for existing practitioners looking to develop their CPD skills as well as nursing and other health professionals working in emergency and urgent care settings.

• Each chapter includes examples, practical exercises and clinical scenarios, helping the reader relate theory to practice and develop critical thinking skills
• Covers not only acute patient management but also a range of additional topics to provide a holistic approach to out-of-hospital care
• Completion of the material in the book can be used as evidence in professional portfolios as required by the Health and Care Professions Council

Professional Practice in Paramedic, Emergency and Urgent Care is a comprehensive, theoretical underpinning to professional practice at all levels of paramedic and out-of-hospital care.

1

History Taking

Val Nixon

Faculty of Health Sciences, Staffordshire University, Stafford, UK

Introduction

History taking is the critical first step in detecting the aetiology of a patient’s problem using a systematic approach. Historically, history taking has been the domain of the medical practitioner whilst other professions focused on assessment skills related to particular body systems, or on assessing activities of daily living (ADL) such as communication, eating and drinking, washing and dressing. In recent years, professional boundaries between different healthcare professionals have begun to blur in response to healthcare reform. Subsequently, history taking skills are becoming increasingly important to non-medical healthcare professionals (Kaufman, 2008) and arguably the most important aspect of patient assessment (Crumbie, 2006). History taking should be clear and all elements should be conducted in the same way with the same purpose; to inform patient care, provide clear communication to other professions and prevent repetition and omission of relevant data. This chapter will therefore focus on the history, taking process using the medical model to structure this process. A brief introduction of why history taking is important will be offered followed by tools and mnemonics that you can use to support and guide your questioning techniques when obtaining information. There will be reference to the importance of communication skills needed when taking a patient’s history; however, due to the complexity of this subject area, this has been explored fully in Chapter 2.

Obtaining the information

History taking is a process whereby the patient or others familiar with the patient report relevant complaints (subjective data) referred to as symptoms. Symptoms and clinical signs are ascertained by direct examination (objective data) by the healthcare professional. History taking is like playing detective; searching for clues, collecting information without bias, yet staying on track to solve the puzzle (Clarke, 1999). Essential and active listening skills are required and this is described by Duffy (1999) as the most fundamental communication skill and is central to obtaining a history. An accurate history can provide 80% or more of the information required for diagnosis (Epstein et al., 2008; Bickley and Szilagyi, 2009). The clinical examination and/or diagnostic testing should only confirm or disprove this diagnosis.

Medical histories vary in their depth and focus from case to case and according to their purpose. The medical history has a traditional format (see Box 1.1) which is considered the ‘gold standard’ (Bickley and Szilagyi, 2009). This provides a systematic approach, yet will generally require a flexible attitude and questioning techniques as opposed to a rigid interrogation or a checklist of questions.

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Box 1.1 Traditional medical history

Date and time

Identifying data

Presenting complaint

History of presenting complaint

Past medical history

Previous illness and surgery

Drug history

Allergies

Family history

Social history

Mental health history

Review of systems

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There will be circumstances where a comprehensive history is required such as:

• Where reaching the diagnosis is difficult or complex
• Where the patient has a range of different health problems
• When the patient is a new patient in the hospital/GP setting
• Baseline for future assessments

Otherwise, there will be circumstances where the history should be more selective which is described as a focused history (Rushforth, 2009). Selected questions are directed towards the presenting problem or need may be more appropriate such as:

• Emergency situations where it is necessary to undertake a primary survey
• Minor illness or information where the information can focus directly to the patients’ problem
• General mental health assessment

Irrespective of which approach is used, the history-taking process allows patients to present their account of the problem and provides essential information for the healthcare professional. It provides the opportunity for the patient to tell their story with an unfolding of symptoms, problems and feelings. It is important to recognise that patients tell their stories in different and usually unstructured ways which may lead to necessary information being omitted. It is, therefore, imperative for the practitioner to use effective communication skills within a systematic framework (see Chapter 2). This will prevent information being overlooked that is essential for diagnostic accuracy. There are several systematic frameworks to support the history-taking process. AMPLE (see Box 1.2) is advantageous for situations where depth and focus of the history are based on the case at hand. It is quick and easy to use especially in an emergency situation. A disadvantage of this framework is the lack of enough detail and structure to enable generation of a patient’s condition, especially when asking events leading up to the emergency. Subsequently, the potential to miss out relevant questions is possible.

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Box 1.2 AMPLE survey

Allergies

Medication/drug history

Past medical history

Last meal or oral intake

Events leading up to the emergency

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Identifying the data

Start the history-taking process by identifying the age, sex, occupation and marital status of the patient. This will become important through other sections of this process. This source of information is generally obtained from the patient, but can also be obtained from a family member, friend or from a written source. Where appropriate, it is important to identify and record the source of information, as the accuracy of information obtained may be questionable. The patient’s mood, memory, trust and clinical condition may affect the reliability of information given and these factors must also be identified and recorded.

The presenting complaint

Normally, the presenting complaint (PC) may only consist of two signs and symptoms; for example, ‘chest pain’, ‘ankle injury’ and ‘feeling unwell’ are initially reported and recorded. A range of differential diagnosis will be considered at this point of the history taking process. It is important to gather further information to eliminate some of the differential diagnosis and consider causes as to why the patient has sought medical assistance (Gregory and Murcell, 2010).

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History of presenting complaint

This section of the process is the main component of history taking. A detailed and thorough investigation into the current illness is performed to provide a complete, clear and chronological account for the PC(s) prompting the patient to seek care. This usually comprises two sequential (but overlapping) stages:

• The patient’s account of the symptoms
• Specific, detailed questions by the health professional undertaking the history

To obtain the patient’s account of symptoms, the use of open-ended questions is required. This is to avoid a yes or no answer so that the patient can expand on their story. For example, ‘tell me more about your chest pain’ encourages the patient to tell the practitioner more. In contrast, closed questions such as ‘is the chest pain severe?’ can be answered in a ‘yes’ or ‘no,’ which is useful for seeking specific answers that are required to gain a deeper understanding of the patient’s problem (Kaufman, 2008).

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It is important to listen to patients as they tell you their story as generally they are telling you their diagnosis. Listening should be an active process and patients should be given every opportunity to talk freely at the start of the consultation with minimal interruption (Marsh, 1999). A common mistake is for the health professional to intervene too early, and research has shown the importance of listening to patients’ opening statements without interruption (Gask and Usherwood, 2002). Once a patient has been interrupted, they rarely ...

Table of contents

• Cover
• Title Page
• Copyright
• List of Contributors
• Introduction
• Acknowledgements
• Chapter 1: History Taking
• Chapter 2: Consultation and Communication Skills
• Chapter 3: Clinical Decision Making
• Chapter 4: Evidence Based Practice
• Chapter 5: Reflection and Reflective Practice
• Chapter 6: Professional and Legal Issues
• Chapter 7: Anti-discriminatory Practice
• Chapter 8: Medicines Management
• Chapter 9: Continuing Professional Development and Portfolio Development
• Index