pt assess history taking
DESCRIPTION
TRANSCRIPT
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PARAMEDIC CARE:PRINCIPLES &
PRACTICE
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Patient Assessment
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The History
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The ability to elicit a good history lays the foundation
for good patient care.
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Source of History
Patient Family Friends Police Others
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Setting the Stage
If a patient’s chart is available, review it before interviewing the patient.
Use this information to gain clues about the patient.
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Reliability
Memory Trust Motivation
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Patient Rapport
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The First Impression
Present yourself as a caring, competent, and confident health care professional.
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When you introduce yourself to the patient, shaking hands or offering a
comforting touch will help build trust.
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Asking Questions
Use a combination of open-ended and close-ended questions.
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Language and Communication
Use appropriate language. Use an appropriate level of
questioning, but do not appear condescending.
When encountering communication barriers, try to enlist someone to help.
Actively listen.
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Active Listening
Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
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Sensitive Topics
A paramedic must learn to become comfortable dealing with sensitive topics.
It is important to earn a patient’s trust.
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The Comprehensive Patient History
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Elements of the Patient
History
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Preliminary Data
Date and time Age Sex Race Birthplace Occupation
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The Chief Complaint
This is the pain, discomfort, dysfunction that caused the patient to request help.
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The Present Illness OPQRST-ASPN
Onset of the problem
Provocative/
Palliative factors Quality Region/Radiation Severity Time
Associated Symptoms
Pertinent Negatives
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Past History General state of health Childhood diseases Adult diseases Psychiatric illnesses Accidents or injuries Surgeries or hospitalizations
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Current Health Status
(1 of 3)
Current medications Allergies Tobacco Alcohol, drugs, and
related substances Diet Screening tests Immunizations
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Current Health Status
(2 of 3)
Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and
significant others Daily life
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Current Health Status
(3 of 3)
Important exercises Religious beliefs The patient’s outlook
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You should take your patient’s medications with you to the
hospital, when practical.
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Review of Systems
A system-by-system series of questions designed to identify problems your patient has not already identified.
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Systems
General Skin HEENT Respiratory Cardiac Gastro-Intestinal
Urinary Male/Female
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Special Challenges (1 of 2)
Silence Overly talkative
patients Multiple
symptoms Anxiety
Depression Sexually
attractive or seductive patients
Confusing behaviors or symptoms
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Special Challenges (2 of 2)
Patients needing reassurance
Anger and hostility
Intoxication Crying
Limited intelligence
Language Barriers Hearing problems Blindness Talking with
families or friends
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If the patient cannot provide useful information, gather it
from family or bystanders.
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Summary
History taking techniques Active listening The comprehensive health
history