Investigate the Chief Complaint (History of Present Illness)

What are the first steps to take when investigating the chief complaint (History of Present Illness)?

Begin by making introductions, make the patient feel comfortable, and obtain permission to treat.

How should you address the patient during history taking?

Refer to the patient as Mr., Ms., or Mrs., using the patient’s last name.

What types of questions are helpful to determine the chief complaint?

Ask a few simple and direct questions; open-ended questions help determine the chief complaint and identify any associated complaints.

What nonverbal communication techniques support effective history taking?

Use eye contact to encourage the patient to continue speaking and repeat statements back to show understanding.

What behaviors should be avoided and encouraged when taking a patient’s history?

Do not interrupt the patient and be empathetic of the patient’s situation.

How can information about the chief complaint be gathered?

Gather information from observable clues and information received from the original dispatch.

If the patient is unresponsive, where can you obtain information about their condition?

From family members present, witnesses, bystanders, medical alert jewelry, or other patient medical history documentation.