1. Introduction
Clinical history taking is a core skill in every specialty. A good history is structured, patient centred and focused on the presenting problem while still capturing key safety information.
2. Opening the consultation
Introduce yourself, confirm the patient''s identity and explain your role. Use an open question to let the patient describe the main concern before moving to focused questioning.
3. Core structure
Cover the presenting complaint, history of presenting complaint, relevant systems review, past medical and surgical history, drug history, allergies, family history and social history. Clarify baseline function and red flag features when relevant.
4. Closing the consultation
Summarise the key points back to the patient, check for understanding, ask if they have concerns or questions and explain the next steps.
Opening
Presenting complaint
History of presenting complaint
Systems review
Background history
Closing