CH 12 - RAD

Chapter 12: History Taking

Objectives (1 of 2)

  • Describe the role of the radiologic technologist in taking patient clinical histories.

  • Discuss desirable qualities of a good patient interviewer.

  • Differentiate between objective and subjective data.

Objectives (2 of 2)

  • Explain the value of the six categories of questions useful for obtaining patient histories.

  • Describe the importance of clarifying the chief complaint.

  • Detail important elements of the sacred seven elements of clinical history.

Patient History Process (1 of 2)

  • Consider taking a patient history as an interview.

  • Radiologists often never meet the patient directly.

  • The radiologic technologist serves as the eyes, ears, and mouth of the radiologist.

  • History-taking is an essential responsibility of the radiologic sciences professional.

Patient History Process (2 of 2)

  • Information gathered must be accurate and detailed.

  • Genuine interest, attentiveness, and professional competence foster a sense of caring in patients.

Qualities of Interviewer (1 of 2)

  • Acknowledge and validate the patient’s feelings, including anger.

  • Show respect towards the patient.

  • Be genuine and empathize with the patient’s condition.

  • Ensure patients feel that the information they provide is important.

Qualities of Interviewer (2 of 2)

  • Avoid intimidating patients.

  • Pay attention to detail in the interview process.

  • Exhibit accurate note-taking skills.

  • Demonstrate strong questioning skills.

  • Develop multitasking and communication skills.

  • Maintain a polite and professional demeanor.

Data Collection Process (1 of 2)

  • Most patients understand the importance of providing a history.

  • Information needed is specific to the patient's reason for the examination.

  • All patient statements should be taken seriously, even if they don't fit the initial opinion about symptoms.

  • Documentation of collected data must be precise and utilize appropriate medical language.

Data Collection Process (2 of 2)

Objective Data:

  • Perceptible to senses, measurable, often physiological.

  • Include signs that can be seen, heard, or felt.

Subjective Data:

  • Patient feelings, pain levels, attitudes, opinions of observers, and are subject to interpretation.

  • Objective and subjective data are equally important.

Questioning Skills

  • Use open-ended questions to encourage responses.

  • Avoid leading questions that may bias the answer.

  • Facilitate responses by remaining quiet at times.

  • Utilize probing questions for more detail.

  • Repeat patient responses to clarify and confirm understanding.

  • Summarize responses to verify accuracy.

Key Information for Radiologists

  • The patient's chief complaint is paramount for understanding the need for examination.

Essential Question

  • Always ask: "Why is this examination being done?"

Elements of the Clinical History

  • Chief Complaint: Focus on primary issues but allow for multiple complaints if valid.

  • Avoid overlooking secondary symptoms that may provide important context.

Sacred Seven of Medical Histories

  1. Localization

  2. Chronology

  3. Quality

  4. Severity

  5. Onset

  6. Aggravating or alleviating factors

  7. Associated manifestations

Patient History Considerations

  • Ensure patient history data aligns with the requisition.

  • Verify that symptoms support the exam requested.

  • Describe pain characteristics thoroughly:

    • Localized vs. general

    • Location

    • Duration

    • Old vs. new symptoms

Role of Technologist

  • Be an attentive listener and take accurate notes.

  • Ensure answers to key clinical questions are obtained.

  • Present a professional image during interactions with patients.

Conclusion (1 of 2)

  • Treat patient history collection as an interview process.

  • Incorporate both objective and subjective data for a complete medical history.

  • Show respect, compassion, and empathy for the patient's condition.

  • Clearly identify and focus on the patient’s chief complaint.

  • Gather all relevant information for the procedure.

Conclusion (2 of 2)

  • Look for both objective and subjective data.

  • Maintain a professional demeanor.

  • Take detailed and precise notes.

  • Remember: you are often the eyes, ears, and voice of the radiologist when interacting with the patient.