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History Taking
Chapter 12
Objectives
● Describe the role of the radiologic and imaging sciences professional
in taking a clinical history.
● Describe the desirable qualities of a good patient interviewer.
● Differentiate objective from subjective data.
● Explain the value of each of the six categories of questions useful in
obtaining clinical histories.
● Describe the importance of clarifying the chief complaint.
● Detail the important elements of each of the seven sacred elements
of the clinical history.
Patient History Process
• Look at taking a patient history as an
interview of the patient.
• In most cases, the radiologist seldom has
the opportunity to meet the patient.
• Often, the radiologic and imaging sciences
professional is the eyes, ears, and voice of
the radiologist.
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Patient History
• Information gathered needs to be accurate
and specific in detail, if possible.
• History needs to include relevant
information to examination.
• Genuine interest in what the patient has
to say, attentiveness, and an image of
professional competence can provide
patients with a real sense of caring.
Qualities of Interviewer
• Acknowledge patient’s anger, if present.
• Respect the patient.
• Be genuine.
• Empathize (not sympathize) with patient’s condition.
• Patients need to feel the information they are providing, is important.
• Don’t intimidate patients.
• Be attentive to detail.
• Demonstrate accurate note-taking skills.
• Have good questioning skills.
• Develop multitasking, communication skills.
• Always maintain a polite and professional demeanor.
Data Collection Process
● Most patients understand the importance of
a history and will provide information as requested.
● Remember, the information needed by the radiologist
is specific to the patient’s reason for the examination.
● Never disregard anything the patient says, especially if
it does not fit with the opinion you are forming about
the patient’s symptoms.
● Data collected needs to be documented precisely and
clearly, using appropriate medical language.
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Data Categories
Objective Subjective
• Perceptible to senses • Patient feelings
• Able to be measured • Pain level
• Often physiologic • Attitude
• Signs that can be seen, • Opinion of observer
heard, felt, etc. • Subject to interpretation
Neither category is more important than the other.
Questioning Skills
• Use open-ended questions.
• Avoid leading questions.
• Facilitate a response from the patient.
• Remain quiet to get a response.
• Use probing questions to focus in on more
detail.
• Repeat patient response to clarify and confirm
information collected.
• Summarize to verify accuracy.
What is the main thing the
Radiologist wants to know about the
patient history?
The patient’s chief
complaint
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If you have to ask just one basic
question when taking a history,
ask the following:
Why is this exam being done?
or
Do you know why your doctor
ordered this exam?
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Elements of the Clinical History
Chief Complaint
Focus Add Don’t Ignore
MDs tend to focus on a Allow the patient to add Ignoring all symptoms except
patient’s chief complaint more than a single the most predominant can
complaint when multiple cause you to miss other
complaints appear valid. important clinical information.
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Sacred Seven of Medical Histories
Quality 04 Onset
03 05
Severity
02
Localization
06
01 Associated
manifestations
Chronology
07 Aggravating/Alleviating
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Patient History Considerations
Match?
Does the patient history data
match the order? Verify
Ensure patient symptoms
Support? match the exam request
Do their symptoms
support the exam?
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Role of Technologist
Patient Advocate
Get answers to key
Be a good Listener
clinical questions
Take accurate notes and Present a professional
record them appropriately image
You play an important role in
interacting with the patient
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Conclusion
• Consider the patient history as an interview with the patient.
• A complete medical history includes both objective and subjective data.
• Demonstrate respect, compassion, and empathy for the patient’s condition.
• Clearly identify the patient’s chief complaint.
• Gather all pertinent information relative to the procedure.
• Look for objective and subjective data.
• Take accurate notes with attention to detail.
• Never forget, you often are the eyes, ears, and voice of the radiologist with the patient.
• Your observations and assessment are essential to helping the radiologist.
• Present a professional and polite image at all times.
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