Obtaining a Health History From a Family Member

When patients are older, obtaining a adept history—including information on social circumstances and lifestyle in add-on to medical and family history—is crucial to good wellness care.

The varied needs of older patients may require different interviewing techniques. The following guidelines can help you obtain a thorough history of electric current and past concerns, family history, medications, and socioeconomic situation.

These suggestions are less time-consuming than they may appear. Some involve a single investment of time. Other health care professionals in the office or home may assist in gathering the data. You may want to get a detailed life and medical history as an ongoing office of older patients' part visits and apply each visit to add to and update information.

General suggestions

Y'all may demand to exist especially flexible when obtaining the medical history of older patients. Here are some strategies to make efficient use of your time and theirs:

• If feasible, try to gather preliminary data before the session. Asking previous medical records or, if in that location is time, mail forms that the patient or a family member can complete at dwelling house. Try to structure questionnaires for easy reading by using large type and providing enough infinite between items for people to respond. Questionnaires to make full out in the waiting room should exist brief.
• Try to have the patient tell his or her story only once, not to another staff fellow member and and so again to you. For older patients who are sick, this process tin can exist very tiring.
• Sit and confront the patient at centre level. Use active listening skills, responding with brief comments such as "I see" and "okay."
• Exist willing to depart from the usual interview structure. You might empathize the patient'southward condition more quickly if you elicit his or her past medical history immediately after the chief complaint, earlier making a complete evaluation of the present illness.
• Try to apply open up-ended questions that encourage a more comprehensive response. If the patient has trouble with responding, be prepared with yes-or-no or uncomplicated-choice questions.
• Remember that the interview itself can be benign. Although you run into many patients every mean solar day, yous may be the only person your patient is socially engaged with that solar day. Your attention is important. Giving your patient a chance to limited concerns to an interested person can be therapeutic and can build trust.

Elicit electric current concerns

Older patients tend to have multiple chronic conditions. They may have vague complaints or atypical presentations. Thinking in terms of current concerns rather than a master complaint may exist helpful. You might kickoff the session by asking your patient to talk nearly his or her major business organization, "Tell me, what is bothering you the about?

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Ask questions

Ask, "Is there anything else?" This question, which yous may have to echo several times, helps to go all of the patient'due south concerns on the table at the beginning of the visit. Sometimes, an older patient will seek medical care considering of family members' or caregivers' concerns.

The main concern may not be the kickoff one mentioned, particularly if it is a sensitive discipline. If there are besides many concerns to address in ane visit, y'all can plan with the patient to address some now and some next time.

Encourage the patient (and his or her caregivers) to bring a written listing of concerns and questions.

Discuss medications with your older patient

Side furnishings, interactions, and misuse of medications can lead to major complications in older people. It is crucial to notice out which prescription and over-the-counter medications older patients are using and how often. Older people often take many medications prescribed by several dissimilar doctors, such as internists, cardiologists, urologists, or rheumatologists.

Recollect to inquire about whatever alternative treatments, such as dietary supplements, complementary remedies, or teas that the patient might exist using. Remind patients that it is important for you lot to know all the over-the-counter medicines, such every bit pain relievers or eye drops, they employ.

Suggest that patients bring a list of all of their medications—prescriptions, over-the-counter medicines, vitamins, supplements, herbal medicines, topicals, liquids, injectables, and inhalants—along with how much and how oftentimes they take each medicine. Or, you lot could advise that they bring everything with them in a bag. Find out about the patient's habits for taking each medication, and check to exist sure that he or she is using it as directed.

Check to come across if the patient has (or needs) a medical alert ID bracelet or necklace. At that place are several sources, including MedicAlert Foundation International.

Gather information by asking about family unit history

The family history is valuable, in part because it gives you an opportunity to explore the patient's experiences, perceptions, and attitudes regarding affliction and death. For example, a patient may say, "I never want to be in a nursing domicile like my female parent." Be alarm for openings to discuss issues such every bit advance directives.

The family unit history not only indicates the patient's likelihood of developing some diseases but likewise provides information on the health of relatives who care for the patient or who might practise so in the time to come.

Knowing the family structure will aid y'all to know what support may be available from family unit members, if needed.

Enquire nearly functional status

Understanding an older patient's usual level of operation and knowing almost any recent significant changes are fundamental to providing appropriate health care. They too influence which treatment regimens are suitable. The ability to perform bones activities of daily living (ADLs) reflects and affects a patient's health.

Depending on the patient's status, enquire about ADLs such equally eating, bathing, and dressing and more complex instrumental activities of daily living (IADLs) such equally cooking, shopping, and managing finances. At that place are standardized ADL assessments that can be washed apace and in the office.

Sudden changes in ADLs or IADLs are valuable diagnostic clues. If your older patient stops eating, becomes confused or incontinent, or stops getting out of bed, look for underlying medical problems. Go on in mind the possibility that the problem may be acute.

Consider a patient'due south life and social history

If yous plan to continue caring for an older patient, consider taking time to acquire nigh his or her life. A life history is an excellent investment. It helps to empathise the patient. It also strengthens the physician-patient relationship by showing your interest in the patient as a person.

Exist alarm for data about the patient's relationships with others, thoughts about family members or co-workers, typical responses to stress, and attitudes toward aging, illness, work, and decease. This data may help you interpret the patient's concerns and make appropriate recommendations.

The social history is likewise crucial. If you are aware of your patient'due south living arrangements or his or her admission to transportation, you lot are much more likely to devise realistic, appropriate interventions. Ask nearly where he or she lives; neighborhood safety; eating habits; tobacco, drug, and alcohol use; typical daily activities; and work, education, and fiscal situations. It helps to find out who lives with or near the patient.

Understanding a person's life and daily routine can help y'all to understand how your patient's lifestyle might bear upon his or her health care. To this end, determine if the patient is an informal caregiver for others. Many older people intendance for spouses, elderly parents, or grandchildren. A patient'south willingness to report symptoms sometimes depends on if the patient thinks he or she tin "afford to get sick" in view of family unit responsibilities.

House calls by a health care professional are an splendid style to find out about a patient's home life. If that'southward not possible, attempt to learn some details about the patient's domicile life during the interview: "Do you utilise oil or gas heat? Practice you have steep stairs to navigate? Practise you own a pet? Can you get to the grocery store or chemist's shop on your own? Are you friendly with anyone in the neighborhood?"

Learning about your patient's home life volition help you sympathise aspects of his or her illness and may improve adherence to treatment.

Also, exist sure to inquire if anything has inverse since the last visit. For example, you'll want to discover out if your patient still has the same living arrangements or experienced some blazon of loss.

For more information virtually obtaining a medical history

American Occupational Therapy Clan
301-652-6611
www.aota.org

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed: May 17, 2017

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Source: https://www.nia.nih.gov/health/obtaining-older-patients-medical-history

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