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    Patient-Centered Medical History Taking

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    Aulia Azmi
    The document discusses patient-centered medical history taking. It outlines the objectives of teaching students to take medical history based on patient needs and according to standard procedure. It also discusses exploring both the disease and illness experience, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. The general procedure of medical history taking involves verifying the patient's identity, learning the chief complaint and reason for visiting, and obtaining a history of current and past medical problems and the family medical history.

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    Patient-Centered Medical History Taking

    Uploaded by

    Aulia Azmi
    1K views13 pages
    The document discusses patient-centered medical history taking. It outlines the objectives of teaching students to take medical history based on patient needs and according to standard procedure. It also discusses exploring both the disease and illness experience, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. The general procedure of medical history taking involves verifying the patient's identity, learning the chief complaint and reason for visiting, and obtaining a history of current and past medical problems and the family medical history.

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    The document discusses patient-centered medical history taking. It outlines the objectives of teaching students to take medical history based on patient needs and according to standard procedure. It also discusses exploring both the disease and illness experience, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. The general procedure of medical history taking involves verifying the patient's identity, learning the chief complaint and reason for visiting, and obtaining a history of current and past medical problems and the family medical history.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    1K views13 pages

    Patient-Centered Medical History Taking

    Uploaded by

    Aulia Azmi
    The document discusses patient-centered medical history taking. It outlines the objectives of teaching students to take medical history based on patient needs and according to standard procedure. It also discusses exploring both the disease and illness experience, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. The general procedure of medical history taking involves verifying the patient's identity, learning the chief complaint and reason for visiting, and obtaining a history of current and past medical problems and the family medical history.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 13
    At a glance
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    The key takeaways are that medical history taking should be patient-centered, follow standard procedures, and help understand the patient's illness from their perspective to form a holistic diagnosis.

    The objectives of medical history taking are to take history based on patient needs, follow standard procedures, and formulate hypotheses or synthesize individual health problems based on the history.

    The general procedure of medical history taking includes verifying patient identity, understanding the reason for visit, chief complaints, related symptoms, history of current and past medical problems, and family medical history.

    Patient-centered Medical History Taking

    Trevino A. Pakasi Dept of Community Medicine Faculty of Medicine Universitas Indonesia

    Objectives
    At the end of the session, students will be able: To take medical history based on the patients needs To take medical history according to the standard procedure To withdraw hypothesis or synthesize individual health problems based on the medical history taking

    Outline of the course


    Introduction lecture Practicing

    What youve learned?


    Empathy Humaniora Communication skill Interpersonal relation skill

    Exploring both the disease and illness experience


    Physical, History, lab

    Understanding the whole person

    Finding common ground

    Context

    Patient presents cues

    Disease Illness
    Ideas, expectations, feelings, effect on function Disease

    Problems Goals Roles


    Mutual decision

    Illness

    Person

    Enhancing the patient-doctor relationship

    Incorporating prevention and health promotion

    Being realistic

    The patient-centered clinical method. Sumber : Stewart et. Al.(1995)

    Medical History
    Purpose of history taking: Understanding of the complain Understanding the patients feeling Understanding the symptoms or illness when exists Hypothesis of problems and possible cause

    General Procedure
    Verification of the patients identity Reason for visiting the physician Chief complain of illness when occured Other related symptoms if any History of the current problems Pass medical problems related with the current problems Other medical history that might be important Family medical history Specific questions

    Verification of identity
    Full name Age or date of birth Address Background of the patients: formal education, working, insurance coverage

    Remember to start the conversation by interpersonal touch!

    Reason of visiting
    Usually patients visit regarding his/her concern of any existing health problems / presence of illness Patients goal to be healthy Patients goal to reduce risk

    Formulation of medical history


    Identity Chief complain / reason to visit Other related symptoms History of the current problems Pass medical problems Medical history in the family

    Specific question
    For example in pediatrics patient: history of birth, lactation, immunization, growth and development For example in obstetrics patient: menarche, monthly cycle For example in eldery: daily activity at home For example in psychiatrics: pre morbid condition, personality

    Specific question in family medicine service


    Related with the family: Family tree Family cycle Functioning in the family Culture and habbits in the family Housing and environment

    Formulation of holistic diagnosis


    Aspect 1: patients concerned, knowledge, perceiveness, worries Aspect 2: clinical / medical problems POMR Aspect 3: internal factors Aspect 4: external factors Aspect 5: disability score

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