TAILIEUCHUNG - mosby paramedic (18)

9/10/20121Chapter Taking2Learning Objectives.• Describe the purpose of effective history .taking in prehospital patient care• List components of the patient history as .defined by the National EMS Education .Standards• Outline effective patient interviewing .techniques to facilitate history taking. 3Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Objectives.• Describe how the paramedic uses clinical .reasoning• Outline the process to determine differential .diagnoses• Identify strategies to manage special .challenges in obtaining a patient history. 4History Taking.• Details gathered during interview with patient.• Provides account of medical, social events in .patients life.• Indicates environmental factors that have an .impact on the condition5History Taking.• Gives structure to patient assessment.• Crucial to establish priorities in patient care6Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning History Components.• History obtained in prehospital setting.– Focused on problem or reason EMS was .summoned, problem‐based history 7Patient History Components.• Several purposes.– History places emphasis on identifying life‐.threatening conditions requiring immediate .intervention.• Gives full attention to “needs of moment”.• Patient provides information, leads, appropriate care .for urgent, emergent, and nonemergent patient.• Identifies potential life threats, existence of current .life threat8Patient History Components.• Can be expanded when appropriate.– Allows patient education.– Opportunities to provide service referrals to .agencies, organizations, help with specific health .care needs9Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning History Content .• Each part has specific purpose.– Offers “snapshot” of patient condition.– Date, time obtained.– Identifying patient information.•.•.•.• (can be key to identifying problem)10Patient History Content .• Documentation should include source of .referral, patient history.– Who requested EMS assistance.– Paramedic decides whether source of referral, .patient history are reliable11Patient History Content .• Chief complaint is main part.– Reason why EMS was summoned.– After identifying chief complaint, obtain history .with description of present illness, injury.• Provides chronological account of patient symptoms– Next, question about past medical history, current .health status.– Perform body systems review, appropriate to .patient’s symptoms, © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Taking Techniques.• Set stage for good encounter, establish good .first impression, make environment conducive .to free‐flowing communication.– Establish professional demeanor with patient.– Ensure patient comfort, provide safe environment.– Greet patient by name, surname.• Avoid demeaning terms such as “Granny,” “Pop,” .or “Hon” 13History Taking Techniques.•.•.•.•.•Avoid entering patient’s personal about patient’s sensitive to patient’s feelings, for signs of appropriate, easily understood language14History Taking Techniques.• Ask open‐ended questions, direct questions .(if needed).– Opening questions determine why patient is .seeking medical care, advice.– Facilitation.• Use posture, positive actions, words to encourage .patient to say more.• Maintain eye contact.• Use phrases like “go on,” “I’m listening” to encourage .continued talking .15Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company5.

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