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Old 06-10-2013
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Question How to gather history in an organized fashion?

Hi,

I just started practicing for the cs and my history taking is very disorganized with a lot of pauses during the interview because I have to think. It takes me way more than the recommended 6 to 7 mins. I was hoping somebody could help me out with standard questions that must be asked and how to ask questions relevant to the CC in a systematic way so nothing will be missed. Thanks.
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Old 06-10-2013
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I had the same problem initially. The key is to use mnemonic. This is how I proceed:

1- Normal introduction protocol (your name, his/her name, greeting, draping, "Hello", "Everything comfortable?", Explain what you are going to do, "May I sit down and take some notes?"

2-Present Illness - LIQOPRAAA {Just dig in, ask in/out about the present problem}

3-ROS - Ask screening questions for the systems. Start with the most relevant, and you can skip the less important ones.

4-PAMHITSFOSS (Although I use my own extended mnemonic for social)

5-Summarize

6-Wash hands/wear gloves + ask concerns.

7-P/E ; Ask any questions you missed during the history

8-Counsel

9-Get out!

Dont forget to use transition sentences. "Now I am going to ask about Social history" etc

Last edited by Smashingdude; 06-10-2013 at 07:55 PM.
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Old 06-11-2013
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Thanks a lot smashingdude. I will try that.
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Old 06-11-2013
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I have another question. I have to write down everything the pt says because I don't trust my memory when I get nervous, anxious and stressed. I've been writing down all the symptoms I'm asking and writing "yes" or "no" based on the pt's response. That obviously takes more time and again leads to a lot of silence as I'm writing. Should I train my self only to write down the "yes" answers and assume what I didn't write is a "No"?

Thanks.
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Old 06-11-2013
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Quote:
Originally Posted by ifss View Post
I have another question. I have to write down everything the pt says because I don't trust my memory when I get nervous, anxious and stressed. I've been writing down all the symptoms I'm asking and writing "yes" or "no" based on the pt's response. That obviously takes more time and again leads to a lot of silence as I'm writing. Should I train my self only to write down the "yes" answers and assume what I didn't write is a "No"?

Thanks.
I know the time constraints when writing down. Have the same problem. Thats why I have developed my own abbreviations, and then just cross them out if the answer is no.

Eg, I first write down LIQOPRAA, and then next to each write the appropriate thing that the patient said. Then, in review of system, I just use abbreviations (eg N/V for nausea/vomiting, Hd for headache, W/N for weakness/numbess, D/C for diarhea/constipation, ChP/Dys for chest pain,Dyspnea etc). I just ask them, and if relevant, I write them down, otherwise just cross them. Same in PAMHITSFOSS. Just cross them if irrelevant (eg parents are healthy, just cross F). If relevant, eg Father died of MI, write next to F.

But use your own abbreviations!!! This is what I am doing now. Make abbreviations for everything, and stick to it. Its for your understanding anyway, so it can very well be symbols, letters, shapes or whatever suits you.
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