Subjective history taking essay PDF

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Word Count:1171 Student ID:201602132

Title of Assignment: What information that can and should be obtained/recorded by the clinician during subjective history taking, and why this information is important for forming the clinical impression?

INTRODUCTION Subjective History taking is a way of easing and legitimizing the clinician’s job. It is a form filling method which covers a lot of information about patient that helps the clinician later about diagnosing the problem and assessing it in the most proper style. It shows itself in a main approach to the injury called SOAP which the “s” letter stands for subjective. Therefore, it is the first step for a clinician to reach the conclusion which can be defined as clinical impression. It provides the personal info of the patient like; his name, address, email, GP name, date of birth to help the clinician to be able to contact to the patient after the examination. In addition, it fills the important gaps about patient’s present condition and any harmful factor that could affect the treatment or patient’s life. To that end, it is extremely important to take this varied information before taking any further steps with the patient.

MAIN BODY Subjective history taking form is a broad range of information covered in terms of patient’s injury and details. As it is mentioned in the introduction, it is divided into sections as it is easier to collect information. If the universal template is considered, it has _ boxes to be filled up. The information provided in the boxes are; Present Condition (PC), History of Present Complaint (HPC), Past Medical History(PMH), Investigations, Drug History (DH), Allergies and Social and Exercise History respectively. For the clinician, it is a must to be sure of this information provided by the patient is correct since it can also be harmful to the patient if there is any factor limiting the treatment.

As a clinician, before starting to do anything with the patient it is important to explain them why do you need this information and how you will use it. For example, they could be shy to tell you about any other

Word Count:1171 Student ID:201602132

clinician that they have been to or any physical treatment because they started seeing you instead or in addition to their clinician. This means that, if there’s any previous diagnosis about the injury or any treatment they have gone through would tell the clinician what to do with the patient. It is better not to accept them as a patient if the other clinician already started the treatment since it will be dangerous for them to do excess moves. This means that, more than one therapy could result in aggravation of the injury due to overtaxing. Furthermore, it is important for clinicians to collaborate with each other, so it is ethically wrong to start another treatment to the patient without the confirmation of the previous clinician while the treatment is still going on. This means that, patient is likely to be expected to idealize one clinician and devalue the other. Hence any conflictions in treatment will be eliminated. [ CITATION Joh05 \l 1055 ]

The main way to collect all these information is asking appropriate questions to the patient which can lead the clinician to the best and most useful answer. There are 2 types of questions that can be used in subjective history taking. They are; closed and open questions. Closed questions are potentially asked to get a short and brief answer such as Yes or No. For instance; Did you eat lunch today? This kind of questions don’t provide too much unnecessary information, so they speed up deciding process for clinician to have a certain idea about the injury. On the other hand, sometimes, they don’t cover the information needed so that clinician needs to ask further questions to get more detailed answers about the injured area. These are called open questions. They are clear, effective and easy to understand.

To do this type of query, clinician need to use an understandable language to direct patient to give useful answers. For example; What brings you here? Thus, patient needs to describe what they have been through completely. As a result, open questions don not restrict the answers like closed questions. Furthermore, it is also important to choose an appropriate questioning type for a clinician to make patient comfortable to share this information. This means that, the clinician needs to position themselves according to provide space and comfort to the patient. [ CITATION Bic12 \l 1055 ]

Word Count:1171 Student ID:201602132

The suitable type of positioning usually changes from person to person but mostly accepted as sitting at the same level with patient so that you can have a face to face conversation. Moreover, it is likely to give patient the sense of being supported. However, there are also some positioning which must be avoided such as; sitting on a higher level than the interviewee, acting dis-interested or sitting very close to the patient that you invade patient’s personal space.

There are also further aspects that help clinician to improve his communication with the patient such as; nodding, smiling, paying attention on what he is saying to not to miss any remarkable information. These can be defined as non-verbal communication and it makes up 50 to 70% of the human communication. [ CITATION Wei07 \l 1055 ] Communication skills are very important since all people are different and while some are willing to talk, other ones could be closed and silent. To that end, it is a very essential skill for clinicians to get information as much as possible.

Parts of the Subjective History Taking Forms;

 Present Condition (PC) Tells the type of the injury

 History Present Complaint (HPC) Mostly about determining the pain, secondary problems assorted to the main injury and the progression of injury until that assessment day.

 Past Medical History If the patient has had any previous operations or surgeries. If they have any chronic diseases or if any help is taken from other health professional.

Word Count:1171 Student ID:201602132

 Investigations X-rays or imaginary to see the site of injury better.

 Drug History Information of medication used for injury and medication used for chronic diseases (if exists). This can give the clinician useful information about pathological process and may affect the treatment. [CITATION Nic11 \l 1055 ]

 Allergies They can be allergic to any of the tools used to rehabilitate. Therefore, knowing those prevent any impact to the treatment.

 Social and Exercise History

It tells clinicians about how active are the patients in their daily life base. Does the injury effects their work? They need to know if the patient is doing any sports or has any children. It is also important to learn if their injury is restricting any of these so that the clinician can come up with a better solution to them and help them to foresee how long the recovery process will take.

CONCLUSION

Word Count:1171 Student ID:201602132

All in all, the subjective history taking is an extremely important step before treating the patient and helpful when it is taken with the correct approach to the patient. Correct approach and appropriate query methods provide us more and better information. In other words, more the information is, the easier the assessment of injury will be for the clinician. Therefore, a trustworthy clinical impression can be formed.

REFERENCES 1. Weinberg, R. & Gould, D. (2007). Foundations of Sport and Exercise Psychology (4th Ed.) Champaign, IL: Human Kinetics 2. Petty, N. (2013). Neuromusculoskeletal examination and assessment. Edinburgh: Churchill Livingstone/Elsevier. 3. Bickley, L., & Szilagyi, P. G. (2012). Bates' guide to physical examination and history-taking. Lippincott Williams & Wilkins. 4. Norcross, J., & Goldfried, M. (2005). Handbook of psychotherapy integration. Oxford: Oxford University Press....