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Comprehensive Clinical History: The Ultimate Diagnostic Tool

Dr. Sunitha Mathew Dr. Sunitha Mathew Jun 09, 2020 / 4 mins read

Clearly, the most powerful diagnostic tool is the medical history, the dialogue with the patient.”Stewart Wolf

Within any organized healthcare setting oriented towards the best patient care, ‘clinical history collection’ plays a tremendous role. Both the patient and the clinician are mutually benefited from this activity. To the patient, this establishes a connection with the physician where they feel heard and understood. And for the physician, this builds the first step towards patient care; producing the best patient outcomes like decreased symptoms, reduced errors and improved functional status.

The co-founder of Johns Hopkins School of Medicine: Sir William Osler said, “Listen to your patient. He is telling you the diagnosis.”

The importance of Clinical History in making a diagnosis

The clinical history directs the physician towards the bits and pieces to be tracked down during physical examination. This consecutively aids in distinguishing the most relevant problems of the patient from the subsidiary ones allowing the assessment of the primal concerns as thoroughly and meticulously as possible. In effect, a proper clinical history leaves trails that lead to an enriched and accurate clinical decision. Once problems have been identified; classifying abnormal findings, clustering the clinical findings and data, searching the likely cause for the findings, generating a hypothesis and finally establishing a diagnosis becomes extremely easy.

Outcomes accomplished by a comprehensive and focused clinical history

To achieve its full prospect, a clinical history must be ‘comprehensive’ as well as ‘focused’.

A comprehensive history assessment ensures:

  • Fundamental knowledge about the patient
  • Rapport with the patient
  • Patient story apprehension
  • Potential causes for the patient’s concerns are ruled out
  • A reference line for future assessments

A more focused and detailed assessment helps

  • To address worrisome symptoms of the patient
  • To give an in-depth view of the specific body systems.

Components of a Comprehensive Clinical History

Major constituents of comprehensive health history are:

  • Identification of the source of history/authenticity
  • Chief complaints
  • Present complaints
  • Medical history
  • Surgical history
  • Medication history
  • Social history
  • Family history
  • Review of systems

This list holds key to a great deal of essential data for an accurate diagnosis. For example, the chief complaints address the reason as to why the patient had come in the first place seeking care. The presenting symptoms amplify the chief complaints making clear how each symptom has developed. The medical history outlines childhood illnesses and adult illnesses with dates for events. The medication history helps flag drug-drug interactions, drug-disease interactions or even drug-food interactions. The family history could reveal any inheritable disorders or may even influence their response to personal medical problems. The personal/social history could aid gathering data on the patient’s education, occupation, relationship with family and peers, financial status and bad lifestyle habits. The review of systems is a final head to toe survey that uncovers anything that could have been missed out during history collection.

According to an article by Warren Bell, “to know why the patient has come and to know his way of life clarifies the immediate goal of the doctor-patient interaction and sets a screening method that guides selection or rejection of diagnostic procedures.

Arintra: A comprehensive health history taking tool

With the help of Arintra, the existing drag of the present healthcare system will be mitigated. Undeniably, the amount of effort any physician puts into communication with the patient followed by documentation is quite hefty.

As per an observational study titled ‘Four minutes for a patient, twenty seconds for a relative’ done in the Medical University Center of Freiburg (Germany), approximately 11.4% of a physician’s total working time is spent on communication about diagnosis, therapy and psychosocial issues with the patient. In connection to an article by Ammenwerth et al. (Austria), physicians spent nearly 26.6% of their daily working time in documentation work and roughly 27.5% for direct patient care. With almost the same amount of time being spent on documentation tasks and patient care, high-quality patient treatment decisions are compromised.

The aforementioned articles throw light on the workload foisted upon physicians simply for communication and documentation. If we could take patient history collection to a whole new level by incorporating a history-taking tool like Arintra, there awaits a promising future to more reasoning-based healthcare. A standardized documentation system like Arintra reshapes the language and story of a patient into the attributes and aspects of a health history familiar to all members of a healthcare team. To help Arintra achieve its profound motives of unleashing its potential to transform healthcare, these systems have to be approved by regulators, clinicians and the public. Over time, clinicians can propel towards tasks that focus more on human skills like empathy and reassurance.