Continuing Professional Development: Taking a patient history

OverviewThe aim of this module is to provide the reader with a detailed insight to taking a patient history, identifying some key issues and outlining the importance of documenting a patient history. Many paramedic and prehospital practitioners will already be documenting a patient history on a regular basis as an aspect of their everyday clinical practice. A patient report form (PRF), or similar documentation will guide the practitioner. Emergency care practitioners (ECPs) or paramedic practitioners (PPs) may also use a medical model to guide their comprehensive patient history, as outlined in this CPD module. However, for most paramedics and other prehospital or urgent care professionals, the practice of taking a comprehensive patient history is perhaps less familiar. This module will provide the reader with a background to the importance of tacking a patient's medical history and also to consider developing and refining these skills. This module will also help to explain any patient history notes that you may have read as part of caring for a patient. This module is aimed largely at adult patients, although specific issues in relation to children are identified where appropriate.Learning OutcomesAfter completing this module you will be able to:• Demonstrate an understanding of taking and documenting a comprehensive patient history.• Have an understanding of some of the common patient history taking terminology.• Recognize the importance of history taking as a key component in patient assessment.• Begin to develop and apply some patient history taking skills.A note: This history taking outlined in this module is a general approach to taking a patient's history and does not address the specific history taking in relation to an individual illness or disease and therefore is aimed at being generic approach to taking a history from an undifferentiated patient presenting with a health care issue.

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