A comprehensive history-taking is crucial for healthcare professionals, like advanced nurse practitioners, as it helps in understanding the patient's health status, identifying potential risk factors, and guiding further diagnostic and treatment decisions. It often follows a structured approach to ...
Criteria Achieved Qualitative Feedback
(Y/N) 1. Done well? 2. How to improve?
Introduces self and gains consent.
Confirms patient’s name and age
Establishes patient’s presenting complaint (main symptom/s), by
allowing patient to give a brief history
Characterises presenting complaint.
(use SOCRATES if appropriate to do so)
Enquires about associated symptoms within the system relevant to
presenting complaint
Enquires about associated cardinal symptoms and red flags
Undertakes brief systems enquiry * (can do here or towards end of
HX)
Enquires about patient’s past medical history
Establishes patient’s drug history
Establishes if patients have any allergies
Enquires about family history
Enquires about smoking
Enquires about alcohol consumption
Enquires about social history, occupation, lifestyle and exercise
Summarises patient history
Establishes patient’s ideas, concerns and expectations
Outlines initial management * and considers follow up.
No prescribing expected
Shared decision making and checking of patient understanding
evident
Practice Hx taking OSCE generic feedback
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