Obtaining a patient’s history is the first critical step in determining the patient’s illness. Most of the times, a good doctor swears by the fact, that a good history would be enough to make a good diagnosis, if not decrease the number of differential diagnoses. In medicine, a differential diagnoses is the process of distinguishing one disease from the other, especially when one symptom(s) is a part of several diseases. While not exactly arbitrary, broadly this exercise can be quite subjective and hence the emphasis on a protocol or evidence-based approach toward diagnosis.
Components of good history taking include:
1., Chief Complaint.
For what has the patient come to the clinic? Sometimes the patient may identify two or more conditions that they may wish to address. When this happens, we use the checklist in detail for each of the complaints.
Duration.
How long has this condition lasted for? What is its onset? What it is severity/ character?
Location and Radiation
Any home-based treatment to understand the aggravating and relieving factors
2. Past History of similar or related complaint
3. Family History eg. High BP in family members
4. Personal/ Social History eg. habits such as alcohol, smoking, etc and drug allergies
In Digital health platforms, the task of history taking is shifted to the CHWs (Community Health Workers). Thus the value of history taking will depend on the CHW’s ability to elicit relevant information. At Intelehealth we have the required tools (clinical protocols) that will allow the CHW to obtain a relevant and detailed history via app prompts and we also train the CHWs periodically on newer updates or best practice procedures they can implement on the ground. The Hx Guide is a clinical history taking protocol and is akin to a checklist. It is a set of instructions or guidelines on what should be the next logical step, in this instance, what relevant detailed history should be inquired into.
On the Intelehealth app platform, the clinical protocols are developed in a way that allows us to approach the patient’s concerns in a patient-centered and problem-oriented fashion. The patient initiates the Hx guide by describing a symptom. The CHW enters the common condition as presented by the patient and as per the prompts from the app continues to take the history further taking a complete detailed history.
Here’s an example of a CHW taking history using the Intelehealth app’s Hx Guide.
Pic: CHW with her tools (Backpack kit) explaining about the process, taking consent and explaning about data privacy of the data to be gathered in the session.
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Pic : CHW writing down the patient particulars and taking down the history
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