Micro-lectures

Paramedics Course – History Taking (Patient Assessment)

History Taking (Patient Assessment)

Micro Lecture by the Australian Paramedical College

 

In this micro-lecture we’re going to talk about history taking and patient assessment in paramedic practice.  Enrolled students have unlimited access to a rich library of learning materials such as this.

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History Taking (Patient Assessment)


In this session we’re going to talk about history taking. Now, let me be honest with you. History taking is one of the single most important things that you will ever do as a paramedic. You will be meeting patients and people generally that you’ve never met before. Therefore, when you meet them you need to find out what’s going on, why have you been called? What is the problem that they’re presenting with? What can you do for it as a paramedic? Of course, to be able to provide care that is safe and of high quality you need to make sure that the care that you deliver does not cause any harm to your patient.

This will give you guys an opportunity to recognise the importance of history taking in paramedic practice, wherever that practice may be. Use the processes of observation, questioning, and document review to be able to help you in your assessment and management of that patient as well as talking about how paramedics can improve their history taking. Let’s be honest, history taking is not something that occurs naturally and passively. It’s an active process that you need to consistently work on all the time.

Okay, so here’s a figure. This first box here, history taking forms approximately 80% of paramedic practice. Try and think of an of a situation that paramedics attend to. Imagine that you’re sitting on a station and your radio bleeps or you’re sat in the ambulance and you get the mobile, the call on the mobile data terminal and you’re given a private address, 87 John Street. Underneath that address is a little bit of information about the situation. 56 year old male feeling generally unwell. Now, unfortunately for the paramedic that’s sometimes what does happen. You’re given your given very little information. Now to the experienced paramedic it’s actually not a problem because you go into the address, you ask the right questions, you focus in on what the patient’s telling you, you communicate effectively, and you include in listening skills, and then you’re able to undertake a focused in depth history. That then generally leads to some kind of intervention.

That could be something as simple as taking the patient to another healthcare provider, whether it’s a doctor’s surgery or the emergency department, or it might even lead to the paramedic giving some kind of medical intervention like a drug. History taking is really, really important. Now, the reason it says 80% of paramedic practice is because the paramedics have really only got a small amount of skills and things that they can actually do. Now, the rest of the time they’re actually asking questions to be able to make that decision, so asking questions in the right order, at the right time, about the right thing is really, really, really important. History taking skills improve over time, but requires an ongoing commitment for self improvement. Now the reason it says that is just because you’ve learned how to use OPQRS & T to assess a patient’s pain doesn’t mean that that’s all you need to do.

Now history taking it goes way beyond the using the OPQRS & T mnemonic, and eventually over time you’ll learn all these skills and all this knowledge to be able to assess your patient, but bringing them all together is really the important part here, and you’re able to do that both in a clinical setting when you go on placement or when you’re qualified and working as a paramedic, but also when you’re doing your prep classes you’re given opportunities to bring it all together. Now, let’s say you’re qualified and you stopped learning. Now, your history taking is going to take a hit here because if you stop learning the clinical signs and symptoms, the clinical manifestations of diseases and conditions, you’re not going to be able to ask the right questions so you can see how the history taking really does link in to your clinical skills and your clinical knowledge.

History taking links in with learned knowledge. That’s something I’ve just said. That really does exemplify what I’ve just been talking about. You gain learned knowledge from a range of places, including the education provider, including the college, university. You gain it from your own personal readings. You gain it from your mentors, you gain it from family members who may be in the profession. Learned knowledge can form a whole range of, come from a different set of areas and including social media as well. The world is very diverse by today’s standards. When we’re taking a history we’re not just asking questions, we are observing our patients as well. Observation is a very powerful skill. When you walk into that address, within the first 10 seconds and experienced paramedic can work out if they are time critical, if the patient is time critical or non-time critical.

When we say time critical or non-time critical think about the words time critical. Time critical means you don’t have time on your side because the patient is really that unwell. You have to act fast. Now, over the years there’s been this thing called a Pediatric assessment triangle, which is here on the screen. Now over the years that developed to be used more broadly with any type of patient, so we can now use this to be used with any type of patient, child or adult. The Pediatric assessment triangle or the patient assessment triangle consists of appearance. How does your patient look? When you walked into that room and said, “Hello. Ambulance,” did they look at you or did they not look at you? Do they care that you’re in the room? Because if they don’t care that you’re there that’s a really bad sign and usually means that they’re time critical and generally really unwell. Work of breathing. Are they using all their accessory muscles to breathe or are they generally just breathing within a range of 12 to 20, normal, quiet breathing, or is there anything in between those settings of time critical and non-time critical.

Do take a look at the work of breathing. Then finally circulation. Circulation is something you can pick up by looking at your patient as well as by feeling for the patient’s pulse, feeling for the absence or presence of a radial pulse or a carotid pulse. Thinking about things like the rate, the strength for characteristics. This is the patient assessment triangle and you can read all around these different aspects of the patient assessment triangle just by looking at different diseases. For example, an asthmatic who presents the patient assessment triangle will present completely different to a diabetic emergency. Again, another example of how you do need to have a good understanding of certain medical conditions. Ongoing monitoring is something we haven’t yet measured and discussed. Now ongoing monitoring is something that’s really, really crucial to the paramedic.

For example, when your patient has been assessed by you in the first instance, in the amount of time that you spend with that patient, whether it’s five, 10, 15, 20 minutes or more, how does that patient continue to behave? Because you need to make sure you are continually monitoring the A’s, B’s, and C’s of that patient because things can change at a given moment in time.If you’re not consistently measuring that patient’s A’s, B’s and C’s and vital signs you’re not going to pick up when the situation changes. Paramedics, to be safe, have to maintain a level of situation awareness, they have to be flexible, and they have to be good observational skills. They have to have a level of observation that exceeds the general population’s, because there have been reported cases of some paramedics putting a patient into the back of an ambulance, taking them to hospital, and because they’ve been so distracted and focused on the paperwork when they’ve arrived at the hospital they haven’t been demonstrating good observation on an ongoing monitoring skills, which has led to the patient suffering as a consequence. Do make sure that you are continuously monitoring the patient.

A questioning then. When you’re questioning your patient start with a simple question. Something like, why are we here today? When you make that first contact students do ask me what are the first things that I say to my patient once I’ve made contact? It really just is a simple case, as simple as asking, “Hi. Ambulance. My name’s Sam. What’s the problem today? Why are we here? Why have you called us?” There are, of course, going to be some patients who will just start talking on you the moment you’ve arrived. Oh, thank goodness you’ve arrived, guys and girls., I’ve got this awful chest pain. That’s when you start your primary survey of danger response ABCDE, followed by your secondary survey. On this occasion if it’s pain, asking them onset, what were you doing when the pain came on. Provocation, does anything make the pain better or worse?

Quality, how would you describe the pain? Radiate, does the pain go anywhere else apart from the left side that you’ve shown me? Severity, on a scale of naught to 10 how bad would you say the pain was? Timing, how long have you had the pain for today? Usually when you’ve asked the OPQRS&T because the patient’s told you they’ve got pain, you will then move into your sample questioning. Signs and symptoms. Okay, so you’ve told me about the pain. Are there any other signs and symptoms that you’ve not yet told me about? Oh, yeah. I’ve got a bit of nausea and vomiting. I feel quite sick. Okay. A, for allergies. Do you have any allergies that you’re aware of? It could be to medications or to anything outside of the medications.

M stands for medications. Are you taking any medications? Are you taking them as you should be? Have you had any adverse reactions to them? How long have you been taking them for? When did you last have a review of your medications? Have you had any changes to your medications recently? You can see how asking about medications isn’t a simple as just saying are you on any medications? Of course, the more experience you get as a paramedic the better and more knowledgeable you will become around patients’ pharmacology. P stands for past medical history. Now what I tend to do is ask my patients, what is your past medical history? That way it saves the embarrassment of asking for the medication first and then asking the patients to link those particular medications with a certain illness. I will reverse it and say what’s your past medical history, and then what are your medications, and which ones are you taking for that condition? Of course, your own internal knowledge of those drugs and pharmacology will help you here.

L stands for last ins and outs or last meal, and of course, the last meal and the last ins and outs are hugely important when it comes to taking history. E stands to events leading up to the situation. Now, of course, your patient may have already given you that information in the first place. Eventually you will become more focused so an example here, tell me about the pain and we’ve already talked briefly about the OPQRS & T. Now that’s just one pneumonic, but you have to be much more thorough than this to be able to get to the bottom of the pain and that might include questions like, have you had this before? Don’t expect your patient to automatically know what to tell you about, which is why you guys need to develop the skills in asking these questions.

If you have had this before, when did you receive any, did you receive any medical aid for it? Who was that with? For example, was it another ambulance who took you to hospital or did you go to the GP and they prescribed you some treatments? Did they prescribe you any medications? If so, have you been taking them and how have they affected you? When did you take them last? Are there any medical conditions running in the family that you need to tell me about that you can link into this condition? Of course, timing’s really, really important. How long have you had this over the last hours, days, weeks, months, year, and have you had it investigated before? You can start to see how important questioning really is. There are entire textbooks on patient questioning, and of course they all relate to the physical examination and knowledge. You need to make sure that you’re balancing your underpinning clinical knowledge with your ability to ask questions.

Review of documentation. Now, this one’s really, really important. Let’s say you’ve arrived on scene and you’ve been called, let’s just use an example of an elderly person. Now you have to remember that the population is aging and of course, therefore, the social care needs of somebody who’s older really does become quite complex and it has a mixture of chronic needs. In other words, long-term ongoing needs with acute episodes. Generally speaking, paramedics get called to the acute episodes. Let’s say somebody has poor mobility, and they’ve got cardiovascular disease, and they’ve got COPD. This patient is generally going to require some kind of home help if they are physically unable to care for themselves. Now usually some kind of qualified on non-qualified nursing care will come into the home, do the caring for them, whether that’s helping them with their medications or doing a tidy up of the house to help them, or helping them with their toileting and general activities of daily living.

Now, once they’ve come into the house and done those things they really should be documenting, and recording, and monitoring those things that they’re helping them with. Now, it’s a really good example of how paramedics can take a look at the care plans and workout when the last care came in. Where are they due for the next care? Is there a number you can call to help to ask them about this type of patient because again, you’ll know nothing or very little about them. Of course, you can call them and ask them for things like medications and also mental health. Is there any mental health with this patient? Remembering that most elderly patients, I say most, there are facts and figures out there about numbers and percentages, do have some kind of complex mental health needs. Remembering that most of our elderly populations are socially isolated.

That just gives you an example of the importance of being able to review any clinical documentation if that exists. You might also find that patients have been recently discharged from hospital. Maybe another ambulance came and took them to hospital. Then they were discharged and they were given a copy of the patient’s care notes. Sometimes that occurs depending in which state you’re living in, and of course if they’re available you can read them. For example, is the reason you have been called out today exactly the same or are there any related factors, or is it completely different? That’s something you guys will need to start to consider. Then of course, it’s important that you review your own care. You need to be consistently asking yourself, have I done everything right? Have I done, are there any gaps in my care? Have I missed anything?

Of course, reviewing what you’ve been writing about that because remembering that everything that you document gets stored on file for many, many years and actually becomes a legally binding document. In this session, guys, we’ve been talking about the importance of history taking, when to do it, how to do it, and of course continuous reading, reflecting on your own practice, listening to your peers, going online, listening to all the different types of medical knowledge and information, which by today’s standards are really easy. You can sign into Facebook, you can have TED Talks, you can read public journal articles, and all of these things will grow and develop your underpinning knowledge which will then grow your skills and develop your history taking.

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