History taking is the critical first step in detecting the aetiology of a patient’s problem using a systematic approach. Historically, history taking has been the domain of the medical practitioner whilst other professions focused on assessment skills related to particular body systems, or on assessing activities of daily living (ADL) such as communication, eating and drinking, washing and dressing. In recent years, professional boundaries between different healthcare professionals have begun to blur in response to healthcare reform. Subsequently, history taking skills are becoming increasingly important to non-medical healthcare professionals (Kaufman, 2008) and arguably the most important aspect of patient assessment (Crumbie, 2006). History taking should be clear and all elements should be conducted in the same way with the same purpose; to inform patient care, provide clear communication to other professions and prevent repetition and omission of relevant data. This chapter will therefore focus on the history, taking process using the medical model to structure this process.
A brief introduction of why history taking is important will be offered followed by tools and mnemonics that you can use to support and guide your questioning techniques when obtaining information. There will be reference to the importance of communication skills needed when taking a patient’s history; however, due to the complexity of this subject area, this has been explored fully in Chapter 2. Obtaining the information History taking is a process whereby the patient or others familiar with the patient report relevant complaints (subjective data) referred to as symptoms. Symptoms and clinical signs are ascertained by direct examination (objective data) by the healthcare professional. History taking is like