How do you take good history of a patient?

Greet the patient by name and introduce yourself. Ask, “What brings you in today?” and get information about the presenting complaint. Collect past medical and surgical history, including any allergies and any medications they’re currently taking. Ask the patient about their family history.

How do you take maternal history?

First, ask about the gestational age of the pregnancy. Gestation is described as weeks+days (e.g. 8+4; 30+7; 40+12 – post-dates). The last menstrual period date (LMP) can be used to estimate gestation, with Naegele’s rule the most common method (to the first day of the LMP add 1 year, subtract 3 months, add 7 days).

What is history taking in pregnancy?

History taking. The purpose of taking a history is to assess the past and present obstetrical, medical and surgical problems in order to detect risk factors for the patient and her fetus.

What is patient taking history?

obtain a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history (including usual source of and access to health care, childhood and adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, hospitalizations.

How do you summarize a patient’s history?

Summarising. After taking the history, it’s useful to give the patient a run-down of what they’ve told you as you understand it. For example: ‘So, Michael, from what I understand you’ve been losing weight, feeling sick, had trouble swallowing – particularly meat – and the whole thing’s been getting you down.

What is obstetrical history?

An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential.

Why is medical history important in pregnancy?

A patient’s past medical history is particularly relevant during pregnancy, as some medical conditions may worsen during pregnancy and/or have implications for the developing fetus.

What type of question should you ask the patient to begin a patient history?

Ask your patient about any substance use, past or present. Now might be a good time to find out what’s going on at home, too, in terms of who they live with and whether there are any problems. Other things to remember include avoiding the use of medical jargon or technical terms in your questioning.