History taking

History taking is more effective if undertaken systematically. Key areas to address are outlined in Table 3.5, with an illustration of two frameworks, which provide simple contrasting approaches to assessment and the use or not of a mnemonic reminder. These can be very useful when documenting a patient history, as say a nurse prescriber, as they prompt areas to explore and can aid clear reporting. History taking is of course dependant on the ability of the patient to give an account of their medical history. A number of factors may limit this process, such as developmental stage, sensory impairment or mental health. Carers and parents can assist in the process. Patients may also be affected by their social confidence in disclosing information about their skin; for example they may be too embarrassed to discuss genital rashes or symptoms affecting sensitive areas or the effect of a skin condition on sexual activity. Aside to the use of empathy, receptiveness and sensitivity, continuity of contact with a health professional is desirable to develop a relationship and trust. This may lead to a greater willingness for patients to disclose sensitive information. The organisation of services may not permit such continuity, however, where possible it should be planned to ensure continuity of care; nurse-led clinics with agreed caseloads can assist this process. Consultation skills, within which history taking falls, are a neglected aspect of dermatology care and, indeed, they are an issue that has been given very limited attention in the speciality. Effective consultation skills provide a key basis upon which patients may be willing to disclose information relevant to their condition and how they are coping with it. Adequate attention needs to be given to the ability of the practitioner to create a helping or therapeutic relationship, including factors such as empathy, genuineness, self-awareness, ability to negotiate care with the patient, trust building and warmth (Ersser, 1997). This provides a key basis for effective support and education. Consultation skills are discussed further in Psychological and social aspects of skin care and Helping patients make the most of their treatment.

Table 3.5 History taking frameworks.   General Oldcarts (mnemonic)   1. Presenting complaint 1. Onset   2. Previous history of presenting problem 2. Location   3. Previous medical history 3. Duration   4. Drug therapy 4. Character   5. Personal and social history 5. Aggravating factors   6. Systems review 6. Relieving factors   7. Overall appearance on examination 7. Timing     8. Severity