History Taking Template

History Taking Template Wash your hands Introduce yourself, and ask permission to take a history General information Name: Age: Sex: Occupation: Presenting Complaint: A short phrase describing the presenting complaint in the patients own words History of Presenting Complaint: Mnemonic - SOCRATES for pain         Site - Where is the pain? Onset - When did the pain start, and was it sudden or gradual? Character - What is the pain like? An ache? Stabbing? Radiation - Does the pain radiate anywhere? Associations - Any other signs or symptoms associated with the pain? Time course - Does the pain follow any pattern? Exacerbating/Relieving factors - Does anything change the pain? Severity - How bad is the pain? Need to explore the presenting complaint chronologically and incorporate relevant systems enquiries. For example - Chest pain - need to explore cardiovascular, respiratory and GI systems enquiry in the history of presenting complaint as pathology from all of these systems could cause chest pain. Systems Enquiry Specific questions for each system – must be asked for every patient CARDIOVASCULAR Chest pain Palpitations SOB/ SOBOE – quantify Orthopnoea Paroxysmal Nocturnal Dyspnoea Intermittent claudication Oedema RESPIRATORY SOB Cough Sputum production Chest pain Haemoptysis GASTROINTESTINAL Abdominal pain Diarrhoea/ Constipation Dyspepsia/ heartburn Dysphagia Haematemesis/ melaena Wheeze Rectal bleeding Jaundice GENITOURINARY Haematuria Dysuria Increased freq micturition Nocturia Hesitancy/ dribbling Polyuria Vaginal discharge Intermenstrual bleeding Menstrual cycle NEUROLOGICAL Headache Dizziness Visual disturbance/ diplopia Speech disturbance Hearing disturbance Weakness Paraesthesia Numbness Cramps LOCOMOTOR Falls Arthralgia Joint stiffness Rashes Mobility Functional deficit Past Medical/Surgical History Mnemonic – JAM THREADS    J - jaundice A - anaemia & other haematological conditions M - myocardial infarction        T - tuberculosis H - hypertension & heart disease R - rheumatic fever E - epilepsy A - asthma & COPD D - diabetes S - stroke Drug History/Allergies Names and doses of all drugs Compliance Allergies – nature of allergy very important Family History First degree relatives Any significant medical problems If deceased – Age at which deceased and cause of death Social History Smoking:  Current/ Ex-smoker  Pack years – Age started smoking, number of cigarettes per day Alcohol:  CAGE questionnaire  Quantify number of units per day/week  Any episodes of alcohol withdrawal Home circumstances:  Independent/ dependent for activities of daily living – washing/ eating/ shopping/ cleaning  Stairs/ toilet on ground floor/ bedroom on ground floor  Mobility – with/ without aids  Carers  Social support – who do they live with? Family close by? Examination See separate sheet Tests Document systematically    Bedside investigations i.e urine dipstick/ ECG/ BM Blood test results Radiology Impression What is your overall impression and list your differential diagnoses? Plan Further investigations:  Bedside tests  Blood tests  Radiology  Specialist investigations Management:  A clear plan of management for the next 24 hours including interventions (ie antibiotics, fluids)  You should also outline a longer term management plan (i.e. further investigations that may be required)  Clear parameters for aims of treatment – BP/PR/RR.  Clear indications of when the nursing staff should contact doctors  A clear plan for what to do in the event of deterioration  Document any discussions about management with senior colleagues and colleagues from other specialities  Document discussions with the patient and their relatives about the patients management To complete your documentation:  Sign and date your history at the bottom and clearly (and legibly) document your grade and your name