When Adriana Iglesias was just five years old, her mother would walk her to kindergarten. Adriana would stop and sit down multiple times on the two-block journey, complaining that her legs hurt. Her mother was unsure why this was happening, but she suspected that there was something wrong with Adriana’s health. When she visited the family physician, however, the concern was quickly dismissed. The physician simply assumed that this only child was being spoiled. 

Instead of accepting the physician’s admonishment, though, Adriana’s mother consulted specialists at a children’s hospital. Sure enough, Adriana was diagnosed with juvenile rheumatoid arthritis and finally started getting some of the care and treatment that she needed—and the empathy that she deserved.

This scenario illustrates how the patient history, including chief concern, is vital to every other aspect of care. 

“Eighty-five percent of diagnoses can be made by listening to the patient,” says Pamela Wible, MD, a family physician who practices in Eugene, Oregon. “People are complicated and have a lot of things to discuss. Physicians don’t have enough time to really listen to patients in the typical five- to seven-minute appointment, and that is just a disaster for everyone.”

Making the time to elicit input from patients is an essential element of the clinical care process, and one that is helped by refined communications skills from the health care team. This is especially crucial when patients, such as Adriana, present with difficult-to-detect diseases such as arthritis, for which early diagnosis and treatment frequently result in better long-term outcomes, says Marcy O’Koon Moss, senior director of consumer health at the Arthritis Foundation, an advocacy group based in Atlanta. 

Be patient

Unfortunately, patients do not always have the opportunity to tell their stories. For example, physicians typically interrupted their patients within 18 seconds and after they had expressed only one concern, revealed one study published in the Annals of Internal Medicine some 30 years ago and still often cited today.1 Rushed providers are apt to miss key information, which could have a negative impact on patient care. Consider the following: of the diagnostic mistakes resulting in hospitalizations or follow-up visits to an emergency department, urgent care center, or primary care physician within 14 days, 56.3 percent could be attributed to errors related to medical histories.2 

That is precisely why Dr. Wible makes sure that her patients have plenty of time to open up, not just about their chief concern but about their overall health, during the patient history taking process. “You have to understand the motivations for their behaviors, many of which affect their health,” she says. The smallest detail confided to a member of the care team can have a significant impact.

All the write questions

One successful approach to obtaining accurate histories is to start off broadly in scope and narrow the search from there, says Grant Syverson, MD, a pediatric rheumatologist who practices at Sanford Health in North Dakota. 

Dr. Syverson relies on medical assistants to take a patient history before he sees the patient, as well. “It is always good for the medical assistant to learn why the patient is there and to set up the doctor for the appointment and make sure everyone is on the same page. Nothing is more annoying for a patient than for a doctor to walk into the exam room and ask, ‘Why are you here?’” says Dr. Syverson.

Medical assistants can take detailed patient histories by using structured question sets approved by the Centers for Medicare & Medicaid Services (CMS), says Denise Fisher, CMA (AAMA), team care assistant at Family Medicine Mountain View in Greer, South Carolina, a part of Greenville Health System. “The information is then presented to the provider in the presence of the patient to ensure completeness and accuracy. This frees the provider to do what only he or she can do, and that is physical examination and decision making,” she adds. “It has also created greater access to care and ensures that measures are met, including those dealing with meaningful use, CMS, ACOs [accountable care organizations], and others.”  

To ensure that they are taking a complete patient history—and asking all the questions that can help shed light on the patient’s chief concern—many providers employ the OPQRST pneumonic3

O: The onset of the pain or symptoms

  • What were you doing when the symptoms started? 
  • Was the onset sudden or gradual? 

 

P: What provokes the symptoms or pain

  • What makes the symptoms better or relieves them in any way? 
  • What makes the symptoms worse? 

 

Q: The quality of the symptoms or pain

  • Can you describe the symptom (e.g., pain or discomfort) that you are experiencing right now? 
  • Is it sharp or dull?
  • Is it constant or does it come and go?
  • Has it changed since it began? 

 

R: The region of the pain or symptoms

  • Can you point to where it hurts the most? 

S: The severity of the pain or symptoms

  • On a scale of 1 to 10, how would you rate your level of discomfort right now?
  • Using the same scale, how would you rate your discomfort when it began?

 

T: The time when the symptoms began, worsened, or subsided

  • When did the symptoms begin? 
  • Have you ever experienced these symptoms before? If so, when?
  • Is there a certain time of day when the symptoms are better or worse?

 

Such thorough questioning can lead to more accurate diagnoses. Imaging studies and lab tests are invaluable diagnostic tools, but as Dr. Syverson notes, the comprehensive patient history should be standard practice across every field of health care. 

In fact, conducting comprehensive patient histories is likely to improve patient 
care and satisfaction. Care providers can more quickly and accurately diagnose patients and start them on a course toward wellness. Furthermore, when an empathetic patient history has been conducted, patients—such as Adriana and her family—can rest easy knowing that their concerns have truly been heard.