Why History-Taking Matters
The patient history is the cornerstone of clinical medicine. Research consistently shows that 70-80% of diagnoses can be made from the history alone, before any physical examination or testing. Mastering this skill is essential for accurate diagnosis and effective patient care.
A good history also builds rapport and trust. When patients feel heard and understood, they share more relevant information and are more likely to follow treatment recommendations.
Structure of a Complete History
A complete medical history follows a systematic structure:
Chief Complaint (CC)
The primary reason for the visit, in the patient's own words. “I've had chest pain for two days.”
History of Present Illness (HPI)
Detailed exploration of the chief complaint: onset, character, location, duration, severity, and associated symptoms.
Past Medical History (PMH)
Previous illnesses, surgeries, hospitalizations, and chronic conditions.
Medications
Current medications including dose, frequency, and adherence. Include OTC medications and supplements.
Allergies
Drug allergies and reactions, food allergies, environmental allergies. Note the specific reaction (rash, anaphylaxis, etc.).
Family History (FH)
Relevant conditions in first-degree relatives: heart disease, cancer, diabetes, genetic conditions.
Social History (SH)
Occupation, living situation, smoking, alcohol, drugs, exercise, diet, sexual history when relevant.
Review of Systems (ROS)
Systematic screening of each organ system for symptoms the patient may not have mentioned.
The OLDCARTS Framework
OLDCARTS is a mnemonic for systematically characterizing any symptom. Use it to ensure you gather complete information about the chief complaint:
O - Onset
When did it start? Was it sudden or gradual? What were you doing when it began?
L - Location
Where exactly is the symptom? Does it radiate anywhere? Can you point to it?
D - Duration
How long does each episode last? Is it constant or does it come and go?
C - Character
What does it feel like? Sharp, dull, burning, pressure, stabbing, aching?
A - Aggravating Factors
What makes it worse? Movement, eating, breathing, certain positions?
R - Relieving Factors
What makes it better? Rest, medications, positions, eating, antacids?
T - Timing
Is there a pattern? Time of day? Related to meals? Getting better or worse over time?
S - Severity
On a scale of 0-10, how bad is it? How does it affect daily activities?
Open vs. Closed Questions
Effective history-taking uses both open-ended and closed questions strategically:
Open-Ended Questions
Let patients tell their story. Use at the beginning and when exploring new topics.
- ✓“Tell me about your chest pain.”
- ✓“What brings you in today?”
- ✓“How has this affected your life?”
Closed Questions
Get specific details. Use to clarify or confirm information.
- ✓“Does the pain go to your arm?”
- ✓“Are you taking any medications?”
- ✓“Have you had this before?”
Avoid Leading Questions
Questions that suggest the answer can bias responses: “The pain doesn't go to your arm, does it?” Instead ask: “Does the pain go anywhere else?”
Active Listening Techniques
Silence
Allow pauses. Patients often share important information when given time to think. Resist the urge to fill every silence.
Reflection
Repeat key points back: “So the pain started three days ago and has been getting worse.” This confirms understanding.
Clarification
Ask for specifics when needed: “When you say 'a while,' do you mean days, weeks, or months?”
Summarization
Periodically summarize: “Let me make sure I understand...” This catches errors and shows you're listening.
Empathy
Acknowledge emotions: “That sounds really frightening” or “I can see this has been difficult for you.”
Common Pitfalls in History-Taking
- Interrupting too early: Studies show doctors interrupt patients within 18 seconds on average. Let them finish.
- Using medical jargon: Ask about “shortness of breath” not “dyspnea.” Match the patient's language level.
- Assuming prior responses: Don't skip questions because you assume you know the answer. Always ask.
- Focusing only on the chief complaint: The real reason for the visit may emerge later. Stay curious.
- Forgetting the ICE: Always explore Ideas, Concerns, and Expectations. What does the patient think is happening?