History Taking

Core Generalist

Knowledge

CG.K.1

Describe a structured approach to patient history, including systems review

CG.K.2

Identify potential sources of data (e.g. personal health records, medical records, patient, family, carers, pharmacy records)

Skills

CG.S.1

Establish rapport and professional relationship with patients of all ages, their carers and relatives

CG.S.2

Obtain a focussed, efficient and accurate history

CG.S.3

Apply different approaches to history taking as needed in various clinical settings such as acute inpatient, emergency, ambulatory care and telephone/ videoconference consultation settings

CG.S.4

Give appropriate emphasis to functional and social history

CG.S.5

Obtain history of previous treatments including complementary therapies and over-the-counter medicines

CG.S.6

Use a range of strategies to corroborate information given by patient

CG.S.7

Evaluate the history, critically considering the degree of functional impairment, physical findings, and other data

CG.S.8

Revisit the history when the clinical situation is not clear

CG.S.9

Gather accurate data in complex situations, for example culturally and linguistically diverse and confused patients

CG.S.10

Persist in seeking information to assist in clinical decision making

CG.S.11

Create accurate, succinct, legible and timely records of every clinical encounter

Attributes

At.14

Receptivity

At. 2

Adaptability

At.17

Resourcefulness