The patient–carer relationship should be based upon openness, trust and good communication.^1,2 It is therefore essential to have a good understanding of effective communication skills. Whilst there are no set rules for what is effective communication, there are some key skills that are of undoubted value:

There are a variety of communication models that are used and have been used in healthcare over many years. However the use of these models is a blend of personal preference and adaptation to specific situations. There are currently two main models that are commonly seen in practice. Each has inevitable benefits and flaws. The most commonly used models are:

• The biomedical model – This is a practitioner-led model, whereby the focus is upon the disease and subsequent management.
  
• The patient-centred model – This model seeks to holistically assess the patient and shares the decision making and power between the practitioner and the patient.

The biomedical model has recently fallen out of favour amongst the medical profession due to the rigid focus and lack of consideration for the patient experience and subjective effects of the disease process.⁴ The patient-centred model seeks to understand the patient’s experience of the disease whilst considering the whole person and agree a management plan in conjunction with the patient’s wishes. There is no evidence to suggest that either model is more effective or desirable; however consensus of opinion suggests that the patient should be treated as a whole person as opposed to a disease or injury.^1–3

This should not be mistaken for having a relationship with a patient! Any health or medical assessment and history should be considered as a partnership with the patient whereby the two parties work together toward a set goal (often a cure or appropriate treatment). The broad role of the practitioner in this relationship is to:

• Be polite, considerate and honest.
  
• To treat patients with dignity.
  
• Treat each patient as an individual.
  
• Respect patients’ privacy and rights of confidentiality.
  
• To empower the patient in caring for themselves.

This is a structured approach to history taking that complements documentation skills as discussed within this book. It is generally accepted that it is important to have a logical and systematic approach to history taking to ensure quality and adequacy in a health history. As an element of this, consent must be sought prior to any assessment process including physical assessment and questioning. A standardised history taking structure can be seen below.

• Introductions
  
• The presenting complaint
  
• The history of the presenting complaint
  
• Past medical history
  
• Medication history
  
• Allergies
  
• Family history
  
• Social history
  
• Sexual history
  
• Mental health
  
• Occupational history
  
• Systematic enquiry
  
• Further information from a third party
  
• Summary.

Adapted from Thomas and Monaghan (2006)⁴; Douglas G, Nicol F, Robertson C. (2005).⁵

This outline above is just a guide as it will not always be appropriate or relevant to include all areas, for example in the critically ill patient such a history could detract from more pressing issues such as treatment. Each section of the history process will now be broken down and discussed individually.

Introductions

This is a key element in establishing a rapport with the patient and can provide information vital to the assessment of the patient. Greeting the patient with a simple hello is often an adequate verbal approach, as comments such as ‘good morning’ may not always be appropriate for a patient who may receive bad news. The shaking of hands can provide vital information about a patient such as their peripheral circulation (i.e. cold hands) and their neurological status (loss of power). However this may not always be appropriate. Take each consultation upon its own merits. It is vital to gain the name of the patient at the commencement of the history as reliance upon terms such as ‘my dear’ or ‘sweetheart’ may be misconstrued. The use of first names or surnames can also be problematic, as some patients may prefer to be called ‘Mr or Mrs Smith’; however some patients would rather be called by their first name. It is simplest just to ask the patient what they would like to be called, as there are no strict rules. Don’t forget to introduce yourself; this can be either just your name or may include your title (i.e. Paramedic/Technician/Emergency Care Assistant).

The presenting complaint

It is essential to define the problem that has caused the patient to seek medical assistance. This can often be a difficult to ask question as terms such as ‘What are you complaining of?’ or ‘Why have you called for an ambulance?’ may be misinterpreted as implying they should not have called or they are ‘complainers’. As with many areas of history taking it is important to choose a technique suited to each individual. Open questions such as ‘What would you say your main problem is?’ or ‘How can I help you today?’ may be more appropriate.

The history of the presenting complaint

To evaluate the presenting complaint further, questions need to be asked that are aimed at working out the cause of the complaint. The required questions to achieve this can vary widely and are dependent upon experience and knowledge in terms of depth of questioning. Key components of the history of the presenting complaint are:

• Location of the symptom
  
• Duration of symptoms
  
• Onset of symptoms (i.e. provocation and worsening of symptoms)
  
• Aggravating and alleviating factors
  
• Any attributable causes
  
• Previous episodes
  
• Severity of symptoms (i.e. pain score)
  
• Nature of the symptoms (i.e. are the pains continuous)
  
• Any medication use to relieve symptoms.

Past medical history

The previous medical history of a patient is often key in understanding current medical conditions. There is often a strong probability that new symptoms may be caused by long-standing medical conditions. Also consideration of medical history is paramount for safety in treatment regimes as contra-indicated treatments must be avoided. It is important to remember that many patients may not consider conditions such as asthma or hypertension (amongst others) to be significant. It is therefore important to ask not only a generalised open question such as, ‘Do you have any medical conditions?’ but to consider asking about specific conditions such as, ‘Do you have or have you had asthma, diabetes, heart attacks, epilepsy, strokes, high blood pressure?’. This list is not exhaustive so please consider ruling out any history that could relate to the presenting complaint. Do not forget to ask about any previous surgery as this may highlight further medical complications.

Medication history

This can be very important for a number of reasons that may relate to a current complaint, including:

• Contra-indication of treatments
  
• Side effects of current medications
  
• Identification of current medical conditions.

It is important to consider both prescribed and non-prescribed medications, alongside any herbal remedies as they often have a medicinal quality that may affect treatment. Therefore it is useful to ask, ‘Do you take any medicines from your doctor/pharmacist/or any herbal remedies?’. It may also be useful to expand this to enquire, ‘Do you take any tablets, inhalers, or drops for anything?’. This may elicit further information. Ideally the patient will have their medication with them; this allows for you to review them thoroughly paying attention to dates, dosages, compliance with medications and frequency.

Allergies

Consideration of allergies is not only key to the safe administration of medications and treatments, but it may also provide clues to underlying causes of symptoms. Prior to any medication provision the checking of allergies is vital. Ask the patient if they ‘have any allergies or medications that they cannot take?’ this will allow for identification of not only allergies but often medications that they do not perceive as allergies but have been informed not to take by their GP or other healthcare professional. If any allergies or other medications are raised it is useful to clarify what reasons underlie the stated problem. This may give rise to further medical history not already stated.

Family history

With a prevalence of genetic inheritance in certain conditions such as heart disease or cancer among others, the consideration of family medical history may be important. Consider asking:

• Has anyone in your family had a similar problem?
  
• Do any diseases run in the family?
  
• Have any of your family members died at a young age? And if so how?

Social history

This can help to build a general picture of the patient and how the illness/injury is affecting their life. It is important to consider family commitments, occupation, where they live, quality of life at the present time and hand dominance (in the case of upper limb injury). All of these factors may influence either the establishment of a diagnosis or treatment regimen. For example it would be inappropriate to leave an elderly patient at home following a fall if they were unable to cope with the stairs to a flat. It may also be of relevance to enquire about smoking and alcohol consumption as it may relate to the current illness or treatment for the presenting complaint. Areas that should be considered as a part of a holistic social assessment include:

• The ability to cook or provide nutrition for self.
  
• The ability to undertake personal hygiene activities (i.e. washing).
  
• Social conditions such as heating and ability to maintain a healthy living environment.
  
• The ability to dress themselves.
  
• The availability of social support such as friends, family or carers.
  
• Access to healthcare should the need re-arise.

Sexual history

This is not commonly an area for enquiry in the prehospital field and if required should be undertaken sensitively. It may be of relevance in any patient however based upon presenting symptoms (such as vaginal discharge) or history provided.

Mental health