The pressure is on. You are in an acute care setting and there is a line of patients to see, some sicker than others. It is up to you to take a rapid history and initiate care.
The patients are a complex mix: young and old; some with strong local accents, others from overseas who speak English with difficulty. And English is not your first language either. Some are in pain, some are angry and frustrated with the wait, and most are anxious, with equally anxious family members at their sides.
Feeling intimidated?
Absolutely. And that is perfectly normal. Even the most battle-hardened English-speaking healthcare professional would feel the same. Acute care settings are probably similar the world over: team members with allocated roles, all frantically multitasking and juggling limited resources while working as quickly as possible to safely direct patients to a ward for continuing care or back home. You would not be alone.
In hospital, even if you have a clerking form to complete as an aide-memoire, you still need a well-rehearsed bank of questions to extract the necessary patient history, all delivered in a way that shows care, attention and respect.
Where do we begin?
As always, start with the presenting complaint, abbreviated as PC in the notes. Once you have called the patient, introduced yourself and confirmed their identity details, begin with an open question such as: “How can I help?” Then let the patient talk without interruption for up to two minutes, if necessary.
Some patients, however, may simply show you an injured body part, or stop after saying that they are short of breath or have chest pain. You still need the complete story, and using closed questions too early can considerably slow down your history taking.
The remedy? Continue with an open approach and follow up with something like:
- For an injury: “Oh dear”, acknowledging the patient’s pain, followed by “What happened?”
- For an illness: “Okay”, showing concern, then “Tell me more” or “Tell me more about that.”
The importance of silence
Use language such as “Go on”, “I see” or “Ah ha”, supported by eye contact, nodding and open body language. These small signals encourage the patient to continue and reassure them that you are really listening.
Allowing patients to speak until they stop naturally may give you everything you need to know about their symptoms, the impact on their life, what they have done to self-manage so far, and their ideas, concerns and expectations. All that information can be gathered through silence, active listening and encouraging body language.
There is a general practice dictum: “If you only let the patient talk long enough, he’ll tell you everything you need to know to manage him.”
Then ask focused questions
This does not mean that history taking stops there. You still need to follow up on cues and use closed questions to fully understand the patient’s pain, other symptoms, management and allergies. When you are meeting someone for the first time, that can take ten minutes or more.
The point is that, especially when you are stressed and under pressure, it is easy to underestimate how valuable those first few minutes of silence can be. They help you gather information quickly and build that all-important patient-clinician relationship.
