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Patient history

 

Relevant patient history is obtained, reviewed and considered before an exam, procedure or treatment

 

+ Importance of patient history

  • The information gathered for a patient history varies according to the exam/procedure or stage within the treatment process.
  • Patient history influences how the procedure is performed and how pre-treatment planning proceeds.1-3
  • Patient history assists with the interpretation of the results/outcomes.1-3

+ Gathering a patient history

  • Patient history can be gathered from a medical record or the patient and/or caregiver.
  • The environment influences the history-taking process and how complete and informative the answers will be.4
  • The way information is gathered also affects the quality of the patient history:1-5
    • Find a private area to have discussions of a confidential nature
    • Explain to the patient and/or caregiver why this information is required and reassure them that information will only be shared with those involved in his/her medical care
    • Ensure the questions asked are worded to get the information you need, rephrase questions or ask follow-up questions if necessary
    • Listen to the patient’s answers and allow them to guide the interview and identify further investigation4
    • Before proceeding confirm the patient has addressed all questions and concerns he/she feels might be important for the healthcare team to know for this procedure/treatment

 

  • If the history has been taken by someone else, it is important to review and clarify pertinent information.

+ References

  1. Torres LS, Guillen Dutton A, Linn-Watson T. Patient Care in Imaging Technology. 7th Ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2010.
  2. Adler AM, Carlton RR. Introduction to radiologic sciences and patient care. 3rd Ed. St. Louis, MO: Saunders; 2003.
  3. Tierney LM Jr., Henderson MC, eds. The Patient History: Evidence-based Approach. McGraw-Hill Companies, Inc.; 2005.
  4. Malcolm HA. Does Privacy Matter? Former patients discuss their perceptions of privacy in shared hospital rooms. Nurs Ethics2005;12(2):156-166.
  5. Lin YK, Lin CJ. Factors predicting patients' perception of privacy and satisfaction for emergency care. Emerg Med J. doi:10.1136/emj.2010.093807.

 

Validation

October 31, 2011

 

 
Canadian Association of Medical Radiation Technologists
85 Albert St, Suite 1000, Ottawa, ON, K1P 6A4
phone: 613 234-0012 / 800 463-9729
fax: 613 234-1097
www.camrt.ca