Cheat Sheet for Clinical History Taking in OH

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.

Introductions

  • Self
  • 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

Health

  • 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?
  • Self-help?
  • 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
  • Smoking
  • Alcohol
  • Diet/exercise
  • Home/social problems that affecting attendance at work

Disability

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

Work

  • 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

Endings

  1. Inform employee of the type of feedback that will be given to management
  2. Discuss any difficulties foreseen
  3. What are management’s options now? Arrange a review date if necessary
  4. Give any leaflets, information and contact details
  5. 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?

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