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2.1 - Principles of Obtaining a History

from Section 2 - Diagnosis, Assessment, Investigation, Monitoring and Data Interpretation

Published online by Cambridge University Press:  27 July 2023

By
Claire Moorthy
Edited by
Ned Gilbert-Kawai ,
Debashish Dutta  and
Carl Waldmann
Ned Gilbert-Kawai
Affiliation:
The Royal Liverpool Hospital
Debashish Dutta
Affiliation:
Princess Alexandra Hospital NHS Trust, Harlow
Carl Waldmann
Affiliation:
Royal Berkshire Hospital, Reading
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Summary

Key Learning Points

  1. 1. Use a systematic and structured approach to obtain the initial history.

  2. 2. Focus on the relevant features of the patient’s clinical presentation.

  3. 3. Take a more thorough history when the patient is stable.

  4. 4. Ensure knowledge of the SBAR approach to communicate among medical professionals.

  5. 5. Call for additional help early, especially if there are any life-threatening conditions.

Keywords

clinical history takingSBAR
Type
Chapter
Information
Intensive Care Medicine
The Essential Guide
 , pp. 21 - 23
Publisher: Cambridge University Press
Print publication year: 2021

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References

References and Further Reading

1000 Lives Plus. 2011. Improving clinical communication using SBAR. www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/T4I%20%283%29%20SBAR.pdfGoogle Scholar
National Institute for Health and Care Excellence. 2007 (updated review 2016). Acutely ill adults in hospital: recognising and responding to deterioration. Clinical guideline [CG50]. www.nice.org.uk/guidance/cg50Google Scholar
Royal College of Physicians. Acute care toolkit 6. The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient. London: Royal College of Physicians; 2013.Google Scholar
World Health Organization. Patient safety solutions. Volume 1, solution 3. Geneva: World Health Organization; 2007.Google Scholar

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