Clinical history taking format guidelines
Have you ever seen a patient/client for taking a clinical history and missed out a really important section or question? Well here is a cheat sheet to keep tucked under your files or on your phone or tablet to refer to.
- Time available for the appointment
- Role of occupational health:
- advisory to management
- managers make decisions based on operational need
- occupational health cannot override management decisions
- Explanation of assessment
- Consent to continue
- Go through referral form in detail
- History of presenting complaint and effect on client
- When did issues/health problems first start?
- How is it affecting work/home life?
- Number of absences and any impact on work performance
- Outcome of GP visits
- Note any medication prescribed – any side effects?
- Referred to specialist – who/which type?
- Referred for treatment – what/when?
- Treatment planned/receiving?
- Next appointment date?
- Any benefit from treatment?
Consider: does treatment reflect current best practice for this condition? Research required later?
Examination (pick those relevant)
- Assess mental health state
- Assess physical capabilities
- Family/social history
- Home/social problems that affecting attendance at work
Day to day activities:
- Is shopping, reading, watching television, vacuuming a problem?
- What time do they get up/go to bed
- Walking, driving, time limits, difficulties with everyday tasks
- Occupational history relevant to referral/any current work restrictions?
- Changes in working practices?
- Does management know all/some/none about the employee’s health condition?
- Can OH discuss health with management – make a note if consent given
- Engagement with work/manager/company
- Inform employee of the type of feedback that will be given to management
- Discuss any difficulties foreseen
- What are management’s options now? Arrange a review date if necessary
- Give any leaflets, information and contact details
- Any questions?
Next Steps for OH
Is a workplace risk assessment or visit required?
Write the report to management and relax with a cuppa!
Have you any important steps in taking a clinical history that I have missed out? Let me know and I will add them to the list?[contact-form-7 404 "Not Found"]