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Respiratory History Taking Checklist

This document provides a checklist for taking a respiratory history. It outlines 36 steps to follow including introducing yourself, gaining consent, exploring the presenting complaint, taking histories of symptoms, medical history, medications, social history including smoking, and closing the consultation by summarizing and thanking the patient. Key communication skills in respiratory history taking involve active listening, summarizing, and signposting.

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Nehal A. Mohammad
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169 views2 pages

Respiratory History Taking Checklist

This document provides a checklist for taking a respiratory history. It outlines 36 steps to follow including introducing yourself, gaining consent, exploring the presenting complaint, taking histories of symptoms, medical history, medications, social history including smoking, and closing the consultation by summarizing and thanking the patient. Key communication skills in respiratory history taking involve active listening, summarizing, and signposting.

Uploaded by

Nehal A. Mohammad
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

OSCE Checklist: Respiratory History Taking

Opening the consultation


1 Wash your hands and don PPE if appropriate

2 Introduce yourself to the patient including your name and role

3 Confirm the patient's name and date of birth

4 Explain that you'd like to take a history from the patient

5 Gain consent to proceed with taking a history

Presenting complaint
6 Use open questioning to explore the patient’s presenting complaint

History of presenting complaint


7 Site: ask where the symptom is (if relevant)

8 Onset: clarify when the symptom first started and if it the onset was sudden or gradual

9 Character: ask the patient to describe how the symptom feels

10 Radiation: ask if the symptom moves anywhere else

11 Associated symptoms: ask if there are any other associated symptoms

12 Time course: ask how the symptom has changed over time

13 Exacerbating or relieving factors: ask if anything makes the symptom worse or better

14 Severity: ask how severe the symptom is on a scale of 0-10

15 Screen for other key respiratory symptoms such as dyspnoea, cough, haemoptysis, wheeze,
chest pain and systemic symptoms
16 Explore the patient's ideas, concerns and expectations

17 Summarise the patient’s presenting complaint

Systemic enquiry
18 Screen for relevant symptoms in other body systems

Travel history
19 Take a travel history if relevant to the presenting complaint

Past medical history


20 Screen for conditions that increase the risk of respiratory disease

21 Ask about pre-existing respiratory disease

22 Ask about other medical diagnoses and previous surgical history

23 Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the
substance
Drug history
24 Ask if the patient is currently taking any prescribed medications or over-the-counter
remedies

Family history
25 Ask if there is any family history of respiratory disease

Social history
26 Explore the patient’s general social context (accommodation, who the patient lives with, how
the patient manages with activities of daily living, care needs)
27 Take a smoking history

28 Take an alcohol history

29 Ask about recreational drug use

30 Ask about problematic gambling

31 Ask about exercise

32 Ask about the patient’s current and previous occupations

33 Ask about pets and hobbies which may be associated with respiratory disease

Closing the consultation


34 Summarise the salient points of the history back to the patient and ask if they feel anything
has been missed
35 Thank the patient for their time

36 Dispose of PPE appropriately and wash your hands

Key communication skills


37 Active listening

38 Summarising

39 Signposting

Read the full guide at Download our


[Link] GEEKY MEDICS clinical skills app

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