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What Ever Happened to a Good History?

January 10, 2014
ky olsen/via Flickr

ky olsen/via Flickr

By Karen Roush, MS, RN, FNP, clinical managing editor

What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.

A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.

Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about his father’s death at 58 of a heart attack. And you realize it’s not a cough that has brought him in; it’s something more that doesn’t fit a neat checklist of symptoms. An ECG shows some nonspecific changes—nothing dramatic—but knowing what you do based on the history, you start an IV, give him an aspirin to chew, a little nitro, call an ambulance, and he’s off to the ED. Later you learn that he was immediately sent to a regional care center and into surgery for a triple bypass.

True story.

Any good NP can tell you their own version of this story. It was just something the patient said, or the way they said it, that heightened their alertness and led them to a diagnosis that could so easily have been missed.

But taking a good history is a skill that is in danger of getting lost in this age of computer checklist care. (That and eye contact, but we’ll save that for another blog post!) Two recent visits I made to clinics, one for primary care and one for urgent care, found me looking at the backs of nurses’ heads as they ran through standardized lists of questions, dutifully clicking them off a checklist on the computer. The provider at the urgent care center took a look at the answers and then proceeded, silently, with the exam. This may seem extreme, but unfortunately it or something very much like it is too often the norm.

Checklists are great for many things. They can save documentation time and remind us to do things we may otherwise overlook. But they cannot substitute for critical thinking, intuition, and an iterative approach. And they can’t substitute for letting the patient talk through their story, which is often when some very interesting details reveal themselves. I once had a patient who denied any history of early heart disease in his family. The only member of his family who’d died young was his father, who was killed in a car accident when he was 48 years old. It was only after a series of questions asked in different ways as I proceeded with the exam that he “mentioned” that his father’s accident happened when he suffered a heart attack at the wheel. In his mind, it was the car accident that killed his father; to him, the heart attack was incidental, and no checklist was going to get to that fact.

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4 comments

  1. I’m a student radiographer and have found that taking histories for the radiologists is part art and part science.

    Although I’m still learning the skill, I find that assessing the patient’s responses (and following up on them) the most interesting part of a history.

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  2. I concur. There has been a great change in how patient’s histories are collected and in most cases this is due to the way that information is now put into a patient’s EMR. In the majority of cases, Medical Assistants or Nurses are pre-loading information into the patient’s charts and that can be problematic. Many MA’s do not have the clinical knowledge as to what is important and what is not, therefore much information can be eliminated, especially where time constraints are in effect in very busy offices. It is also notable that prior records may not be requested or available and valuable information may not be communicated by the patient or loved one’s, as they may not remember or consider it important.
    That is why it is so important to spend the time and get the full picture, especially with patients that had not seen another provider for a long period of time. We acquire records, not only from their former primary care providers, but from their other specialties (as well as any important procedures that they may have undergone) and make sure that information gets scanned in and pre-loaded into their charts prior to seeing them. This makes getting a history much easier and makes the patient feel confident about our level of care.
    We also request our patients to bring a close relative or spouse to their appointments. This not only demonstrates that we are including their loved ones, but offers us the opportunity for information from others that the patient may have forgotten.
    Priceless.

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  3. Absolutely, Marianna !
    Everyone asks for a medical history, but no one knows how to do one or delve more into obvious questions. Unfortunately, it is often not even considered. The elderly, who often have memory gaps, are left incomplete and the family members not included to clarify.
    Someone in their 80’s comes with a rich medical history.
    The client, and hopefully a family member advocate, needs to be fully involved to get the full medical picture.
    Let’s hope a good medical history does not become a lost art !!

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  4. I agree, a good history is being replaced by the provider scanning the patient’s electronic record on the computer in the exam room or a lap top instead of making eye contact with the patient and truly listening. But then the time allotted for a visit prohibits discovering more than can be addressed in that one visit.

    I think we consumers need to rattle the cage and speak out that this is not acceptable. Change providers if at all possible.

    I was lucky when I practiced in the mid 80s to have had the time to get a good history and to get to know my patients, which builds trust and enhances outcomes. Alas.

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