The Poor Historian
Age-Related Changes that Affect History Giving
Sometimes the older patient is unable to provide a clear history for several good reasons. As we do with children, we need specific strategies to get a complete history. To the right, there are a list of factors that might affect history giving in the older patient.
Click on the factors to the right to learn more.
Sensory Impairment
Older people sometimes have sensory impairment especially hearing loss. Can you track down the hearing aid that EMS left at home? Can you get them into a quiet room? Can you get in close and speak slowly in an even tone of voice? (By the way, shouting just makes it worse!) Can your department purchase a “Pocket Talker” — an easy to use device that functions as a portable hearing aid?
Cognitive Impairment
Older people sometimes have (unidentified) cognitive impairment. Perhaps the reason they have trouble giving a “good” history is because they can’t remember when the pain started or whether they vomited or not! Yesterday can be a long time ago if you have short-term memory loss!
Multiple Complaints
Older people sometimes have a lot of aches and pains and problems and medications and doctors. It can be challenging to keep track of everything (even which ache is new).
Poor Social Network
Older people sometimes have poor social supports. There may be no one around to notice slow incremental changes or to distinguish what is new from what is chronic.
Strategies for Getting a More Accurate History
Important Note
Yes this all takes time, but it takes less time to get the real story today, than to deal with the complications tomorrow!
- Look for allies. Listen to the people who know the patient best. It is imperative to turn family members and caregivers and neighbours into your allies in caring for the older patient. What you’re interpreting as “grumpy old man,” reluctant to answer your questions, may actually represent a significant change in mental status for this person. If you don’t hear and listen to the daughter’s comment, “but this is just not like my dad!” then you will not pick up what is probably delirium from a serious infection or new subdural from an unwitnessed fall. (Review the case of Mrs. Sol in the Cognitive Impairment module.)
- Assemble all the family members around the bed and get their version of things;
- Call family members at home;
- See if you can reach the home care nurse or PSW who sees the patient at home;
- Call the nursing home to get a FULL story on what’s been going on (not just “weak” on the transfer note);
- Read the ambulance record carefully — it often contains details that are not available elsewhere;
- Call the family doctor;
- Review old records FIRST (hospital chart, nursing home chart, ambulance record) – even before you see the patient. It’s probably the most efficient way of gathering a complete past medical history.
Discussion: The Poor Historian
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allied health professionals, collaterl hx, patience, family members
– review the previous file
– make history with the family or residence
– do a careful physical examination
Review the old notes, and get history from caregivers.
Site and provincial medical records (electronic), EMS notes, phone calls to family/facility.
review medical records, external records, ems report, and obtain collateral from family
ok
I call potential other historians — family, physicians, friends. I also read through the chart.
main things are to call the nursing home, read the old chart, and if there is family there talk to them. also to ensure you read the triage note and talk to ems and see what report the nurse got
History so important. No rely on EMS history. Needs to speak to family
collateral history, old chart, Rx, EMS record
Número de contacto por familiares
try to gather information from caregivers or family members
Apoyarnos en sus cuidadores, o su familia cercana evidentemente, gente que nos pueda esclarecer cuando iniciaron síntomas, cuáles síntomas, etc.
Familiares, prehospitalaria, notas anteriores
collateral hx
collateral hx, family
collateral hisrtory
previous records
prescriptions
collateral hx, family
collateral hx
Family
Family is a great resource, as well as ems reports and prior notes
Read the ambulance record
Get a pocket talker
ok
collateral hx from carer, family, GP
Chase letters from specific specialists
Previous notes
Family involvement
Contacting family members and speaking with EMS or home nurse.
Thorough reading of records online, call family members to confirm history, ask EMS for any details of home life/evidence of self-care.
it’s best to speak with the family at first. Different family members see different things or can add what’s missing. Also old notes, EMS reports are key. If these are not available, calling a family member or the nursing home provides sufficient information that may be missing.
Talk to closed family member or caregiver, see old records
My first go to is to access the EMR to ensure I can find a good past medical history and current medications. I also access ‘Connecting Ontario’ to get more up-to-date medical information. This is helpful as a lot of the time the patient may not bring all their medications with them, may not remember the names of medications they are on and may not be able to tell you recent changes in medications (at least they may not classify them as new or recent changes’. My next go to is to speak with a family member if available or close friend or RN if they live in a assisted living facility or nursing home. I find these discussions very helpful for collateral especially if I cannot get a lot of information from the patient.
past records, call fam
Talk to family and friends, restate questions in multiple ways to get more information
Call fam
I typically gather information from caregivers/family members/friends of the client.
sit down with them, spend more time
I try to get to know the patient as best as I can to fully understand the story.
always listen to the helpers
Ask specific questions, use family, meds
talk to family
speak with family/review chart
ok
I absolutely obtain as much outside information as possible, perform full skin exam, and assume I’m still missing something.
Always try to get information from family on scene, and for them to come to the hospital if possible
Stop family from interrupting. “What’s going on TODAY” “what is the WORST thing happening TODAY”
talk to patient firstm, then family, confirm with hospital records or paperwork when they become available.
Making sure to collect history from someone who lives with patient and knows exactly how he has changed in last few days.
Rely on other sources of information – family, caregivers, documentation, and objective information like assessment findings and medications
Talk with family
ok
review chart before seeing patient. call family. just learned to ask ehs re living conditions / evidence
O,P,Q,R,S,T
talk to patient first, then family members. Check for any home-care charts or discuss with nurse/PSW if they are on scene. Review medications and any possible discharge papers from recent hospital visits
Talk to the patient first and then gather more info from spouse, family members and caregivers. Look for prescription bottles or blister packs that might be able to indicate clues on medical history. ask to see if there is a medical information folder.
As a paramedic it is often difficult to obtain an accurate pmHx or old charts as we do not have access to this in the pre-hospital setting. I usually gather the pt’s version of what’s going on, then then listen to the family on scene as well as I try to gather any recent discharge paperwork, doctor’s notes, and referral forms that may be at the pt’s home to get a more clearer picture to provide the ED.
Ask family members, ask simple and concise questions, be specific when asking questions.
talk to family members, review medications, speak to family physician and review old records
interviewing any relevant family members or support people that interact with the pt regularly – if noone on scene, attempt to call/notify immediate family member to elicit stronger hx
ask family members to confirm, repeat story back to them
repeat the story back to them, ask for family/witnesses
Ambulance drivers are the worst.
family members or care workers
talk to family/caregivers
Use of others at scene
a
wow
family members, knowing medication names
As a paramedic I will often talk to bystanders such as family or friends. I look at living conditions, meds and look for patient care folders left by home nursing agencies, just to name a few.
family, environment, get hx several times to confirm details
physical exam talk to family observe enviro
physical exam, family members, observations of their environment
thorough physical exam, ask family open ended questions and the pt yes/no questions if cognitive impared
family, history
Many specific closed questions
look for clues
,m
thank you
ask all bystanders and family for info as well
Try not to ask vague questions that result in vague answers. Confirm answers with family, friends, other caregivers or even bystanders.
HYEAH
Patient recall, bystanders or family, looking at surroundings/environment
same
I ask the patient if they can recall the events that just happened and if there is A WITNESS OR family member to agree with what they are saying. I also use OPQRST as well as SAMPLE
medications, bystander/family
ask caregivers for information
also looking for clues around the house – psw notes, state of the house, etc
.
Review medical record then get the history from family or nursing home.
.
none
.
ok
AL/NH staff notes, calling family.
All the resources listed above
Basically same as above. CVOID has made this harder 2/2 family not in room with patient. Have to talk to the family no matter what, always call SNF.
I typically ask any other family member or witness for details and ask the patient very specific questions
chart review, talk to family members
Calling family or nursing home
Call family members, talk to EMS, reach connecting Ontario and family physician
call family members
request old notes from past hospital admissions
speak to family and old documentation
use family and old documentation
–
n/a
contact family, family doctor, nurse, EMS report, old records at the hospital.
i agree
ywa
okay
Lots of questions, close family members, doctors notes
G
family, records
ok
interview family and caregivers
very helpful information.
Look for allies
Usually we speak to the family members or home where patient is at. In some cases if old notes are available, we do send for them to allow us to better review the patients.
speak to; family members, caregivers, EMS personnel, primary physician, see patient’s record
okay
get collateral information from EMS, family, PCP, and records
review records
prior to evaluation of pt
ok
Collateral information is often obtained from family members, EMS, or calling NH. Chart review is also a major part of obtaining patient info.
.
need further med, surgicalhx
Call family. Speak slowly with patient. Review records from their time in this hospital. Use Clinical Connect (can see their care throughout the region)
Nursing staff and I work together. Review EMS or nursing home reports. Talk with family. Review medical records.
ok
Fellow nurses who have seen the patient before can also help be great sources of information.
.
okay
Always reviews previous records. If come from ALC or rehab always call facility to get a baseline. Often call family to get baseline.
k
need to get full history from any possible source,EMR.GP,spouse,family,VON etc
in my institution we have now electronical documentation. one of the benefits of it is that we have access to a sumary of the patient Hx for those who has been in the hospital before. I usually read it first to collect information and also interacting with patients family. We also get a large number of patient coming from long term care facility so I usually read the transfer form.
collateral info from others, deep dive into chart
Collateral, read notes, ambulance notes, GP letter
Read the chart and call the nursing home or family.
=
x
Sometime it’s all in how you ask the questions.
-get a collateral hx
Medical record
collateral- family
ambulance report
GP
.
Nice info
Review charts and history.
I would ask family or caregiver to gain additional information.
all resources possible
all good sources
use all resources
Use a pocket talker.These should always be available but are often not. I find old chart notes very helpful and of course collateral history from family and caregivers.
As above, calling family members or if came from nursing home then the providers there. Reading through previous chart visits if available. Reading through EMS.
collateral, collateral and more collateral – from any source available
using records/ old charts, talk with family, calling careplace or primary physician
Family, old records. Now with EMR hopefully better history.
talk with family, review chart for baseline history. Any new medications?
Reviewing old records, speaking to family physician and family members. Asking pts about present condition may be appropriate but past may be difficult
neeed to utilize all sources
Family, neighbours, homecare, EMS, facility if possible
family, previous notes, ems, patient
talk w family. look at prior health records. be patient with the pt
k
pk
Collect information from caretaker,persons who spend more time with patient,EMT notes,old admission notes.
Need to collect histories from EMT,caretakers,individuals who spend more time with patient,old admission note .
logged in as Cenac
Interview family members,review old notes and emt notes
when i encounter the elderly patient i first establish what medium of communication is best to gather information such as sign language, patois or written. then i ask the questions.
i also ask family members, caretakers, review hospital charts if previously admitted, EMT notes.
discuss with family members or caretakers (sometimes caretakers know best as they spend more quality time with the patients), review old notes (most times patients have been previously admitted and diagnosed with an exacerbation on an underlying problem
Asking short specific questions, obtaining a collateral history, ask pt what has changed and what they are worried about. Ask about their day to day life and activities to get a sense of baseline function. Look up old admission notes and consults. Check their profile on the EMR if available.
Make sure they can hear me ok – get a pocket talker. Review old records. Made sure to get collateral as best as possible. Use appropriate language.
gather as much info as you can
Try to catch EMS before they leave the department.
ems, family, old charts
maybe more info from the fam, pharmacy, and ems
Getting their family members or caregiver involved
I talk with family members when available. unfortunately, there are often situations where family is lives out of town and not aware of what’s going on. I also gather history from nursing home or assisted living staff if possible.
I usually review the patient’s last few notes and problem list to see if I can get an idea of what their baseline is, and then use the family as resources as well.
review pt chart
chart review, simple questions, speak slow and clear, clarify their answers
family tremendously helps, plus reviewing the chart
I routinely review previous records on file, review EHS and triage notes, and obtain collateral hx from family/care givers.
family, medical charting history
Get collateral info.
boo
makes sense
old records, family members, PCP
Reviewing old records, speaking to family physician and family members. Asking pts about present condition may be appropriate but past may be difficult
Reviso ficha personal anterior ,de consultas o ingresos anteriores y trato de obtener información de la familia o cuidador
talk to family
family, friends, open ended questions, asking questions a few different ways to see consistency, keeping as open a mind as possible
Family, friends, GP reports etc
ok
Review PMH, call family
Patient’s family
family, any records that can be obtained, EMS
family, old records
history from family, review old records
Get history from family members if present or call if time allows. Broad investigations when vague complaints. Speak to EMS directly if patient just brought in. Review clinical history
all the below
Hx from family member, care giver. If not then broader investigations
hx from caregiver or family
I think that we tend to forget that the PHYSICIAN is the historian. We need to change our approach to history taking to ensure the history is accurate and complete.
Be patient – have a quite room – when talking to patient ensure you are looking at them – if family available have them in the room for the interview – contact patients pharmacist if patient unsure of medications – if family not available contact other resources that care for the patient
History from patient’s family or caregivers
family
patient family
ok
ask open ended questions at first but after done with that I ask very specific questions. I also try to involve care giver for history to fill in any gaps or give history if patient cannot provide good history
chart review, prior exam notes, family members, nursing home staff, EMS reports
ambulance notes, patient, NOK or Nursing Home, neighbor, GP
Old records, ambulance chart, family
ask caregivers, files, ambulance, pharmacist, primary care physician, friends and family, neighbours
its helpful to collect information from family members and friends and also revising old medical records
Old records, relatives and/or care givers who know the patients for a period of time and are able to know their baseline cognitive status
old records
Assemble all the family members around the bed and get their version of things;
Call family members at home;
See if you can reach the home care nurse or PSW who sees the patient at home;
Call the nursing home to get a FULL story on what’s been going on (not just “weak” on the transfer note);
At the hospital we work at we Call the Next of Kin if the patient is left unattended and obtain a history from them.
I usually speak with a family member who lives with patient or who has had contact with patient most recently to have an idea of what the patient’s baseline is and quickly review of old charts.
old records, family doctor, family members, neighbours, other healthcare providers in the team
Agreed
old records, family, ems
Collateral history, doctors notes and old records
enter the room knowing as much as you can: EMS, RN, EMR, PCP accompanying referral,etc. Have family that are available join. avoid distractions (don’t take history while IV, monitor, EKG is in progress). Sit, speak loudly and clearly and slowly
improve management
Listen carefully to pt and family and keep parking questions untill you understand what happened
great points
communication techniques
helpful information
multiple sources
try to ask further questions to gain more details.
helpful
k
Talk to family or caregivers
Look at past medical charts
If the patient provides a vague response, try to ask further questions to gain more details. As mentioned by others although family members are a good resource to gain information about a patient’s history, consider whether the family member is a reliable source of information.
While I agree that referring to family members is a good strategy for poor historians, this may not always benefit the patient. For instance, older patients may not be willing to disclose as much information in the presence of family members.
I agree. and often times we dont know what the family dynamic is.
patient, family, chart, primary provider
ok
Use the family or caregiver, family MD, PSW chart
medical chart, family members
i use family, psws, and the chart
parler àla famille ou à la résidence
family and chart
family and the chart
I read the nurse evaluation, the ems report, review the file.
Call the residence the patient is living in.
Make sure the family stay with the patient until i see them
helpful
all good advice
I do the tricks enumerated up here : I read the chart, I question family or nursing home staff, I read EMS report. I just don’t call family physician.
Gain a collateral history from not only partner but children and GP
Ensure DC planner involved in assessment
I speak to relatives, neighbours, friends, or bystanders in person or by phone
Examine available old notes
Speak to EMS team that brought in patient
Chase old notes.
Have caregiver or family member present.
Have patient give history WITH member present for confirmation / modification of history.
ok
ask family/caregivers
look at old records
request outside records
ask family how they are compared to their baseline
Collateral history
involve discussion with relatives and caregivers
engage the medical services that brought patient
access old records
Electronic medical records
Ambulance paperwork
Collateral history from family/caregivers/nursing home
Try asking a different way
Call pt’s GP or pharmacist
Look for a recent consult on the computer, look at the clinic EMR if they are a patient in my clinic, ask to see their blister pack/medication bottles to do a proper medication history, talk to the family, talk to the nurses, talk to EMS
Alwaystry toolleteral Hx from nursing home and NOK
obtain info from family and caregivers
ok
Read old chart, EMS record, call FMD, speak with family members, neighbors, and caregivers, call pharmacy that they use regularly and of course assess the patient using a calm even tone when addressing them
Agree with all the suggestions of reviewing all old records – often the specialist referral/review letters are quite helpful and the other good source of information is the local pharmacist for a complete medication list.
The difficulty I find is that we don’t always do this as it takes time and in the time poor ED this doesn’t always happen.
I do try to review the old chart first. I’ve called family members and care givers. Different styles of questioning.
Get obtain collateral information from family/friends or caretakers and review records.
collateral history from caregivers most important, repeat questions stated in a different way, medication list from pharmacy
EMS trip sheet
NH documents
Old chart
Call NH
Search for NOK
ok
review the records, then ask specific questions to help narrow things down.
I work in a city that has one main acute hospital and one ED. So patients needing acute care can only go to one place. We have an electronic medical record with all old letters from specialists and access to all old imaging (including that done by private providers). We have access via this EMR to a limited view of GP records for the patient so can see drugs (and doses) prescribed and then dispensed by pharmacy, vital signs recorded by GP and community providers and list of GP diagnoses. This is invaluable so can review all this before seeing patient. Then of course family really helpful and caregivers.
call relatives, look for previous records, hearing aid, quite room
call relatives, old charts
very good
great
Check pt’s chart and speak with family members.
As a paramedic and an ER nurse I get to see the pt’s in their home environment and the ER setting. We rely on family members quite a lot on scene.
old charts, EMS records. Doctors offices are difficult due to limited hours of operation
obtain collateral information from family/friends or caretakers
There are often many pearls of wisdom in a good EMS note!
phone calls to relatives/carers
electronic medical record/GP for PMHx
Try to overcome with aid (if there is any sensory impairment, e.g. hearing impairment)
Contact next of kin/other friends or family member for more information
Contact GP/specialist letters
Intranet eMR for more information
Other correspondence between GP and specialists
Other medical records
Sometime patient brings his own previous medical records
inclusion of relatives
old recent medical records
Sounds good, need the team since gathering history from many resources takes time when resources are taxed in the reality of an ED dept.
Family is a good starting point; if in nursing home – caregivers
Speak slowly, but please don’t be condescending. Lets not treat our elderly like they are two. I look to family and friends for collateral, call the family MD if the hour is reasonable. I also search through the past admission, discharge and consult documents. We are fortunate to have a provincial repository into which we dictate.
I think we need to consider the stakeholders for history taking from an elderly person before taking history and collaborate with collateral informations.
speak with the FD and involve family to establish baseline and get a sense of new health concerns.
In my experience, the nursing home personnel usually do not contribute much history. I rarely seem to be able to get someone on the phone who knows anything about the patient, including their baseline cognitive function. Not saying that we shouldn’t try, just observing how rarely it helps.
Allow the time to tell the story and ask anything else?
Patience is a necessity in dealing with elderly
take your time, speak slowly, and be patient.
Call family, next pharmacist and then family MD
take your time or make time to speak to patient/family/review all available documentation
family members, EMR,
For older patients with hearing problems, I often flip the stethoscope around and put the earpiece in patients ear and then talk into the bell. Works like a charm!
Collateral really important (nursing home staff/EMS notes/ old notes/ med profile/ family).
Family members, call the nursing home if more details are required, be patient.
Talking to the patient and people that know them best (eg. family, friends, caregivers), hospital records and using all of them together to synthesize the assessment
Ask family, ring care home, old records, sometimes it just has to wait until morning but it’s important to gather as much as you can at the time and make a note of what still needs clarifying. If family are there at the start but then go home as it gets later you need to make the most of having them there such as discusses resuscitation. Nothing worse than when they finally get to the medical ward and there is no family anymore and they have only gotten worse.
talk with the family
I look up previous admission notes before seeing the client whenever possible. I generally review this history with the client to determine their memory of previous events. Family input is essential but need to be wary of others interpretation of what they observe and not relaying just the facts.
Use all available sources BUT key is to take the time to listen.
Draw wandering conversations back to the complaint at hand.
utilize family
Old medical record,family,caregivers, nursing home call if transfert from there.
As a Paramedics, I obtain as much of a Hx from patient as I can, as well as friends & familyon scene and bring all medications or a list of their medications to ER.
Get help from others
Evaluate past records
utilize the caregivers
obtain it from family and paramedics
family, friends, care givers
family, previous medical file, questioning patient himself
.
family
ok
family
home stenographer. or if unavailable, then family.
Definitely get the family involved. Small changes that may seem insignificant to some might be your clue to solving the underlying problem.
What did the Unicorn tell the Zebra?
U-No-Corn!
care giver, EMS, previous visits, etc
k
Simple strategies: take your time with the patient; talk to the patient, even if you think they might be confused; talk to the relatives (particularly to determine if there have been any recent changes to the patient’s condition); phone the nursing home, or a relative if there is none in the department; try not to discharge an older, frail person if they are on their own – wait for a relative to arrive.
speak to the patient, family members if available or caregivers or call them at home to get appropriate information.
use other resources. family, look at environment of house, survey the scene
use other resources. family, look at environment of house, survey the scene
be patient
trying to find an discharge summary is often the most helpful. If recent it provides PMH, meds, and a thorough overview of the patient.
All of the above
speak to relatives or caregivers who may be present.
Call relatives/ next of kin if they are not present.
Review old notes from previous presentations.
spend more time
speak slowly
speak more
speak whit family
interviewing family members and carers also darel more time for their answers
I communicate with family
Apoyo familiar
Look for caregivers or family members. Try to get past medical record
I agree with sometimes having to contact the relatives over the phone or physically going to find them outside the triage area. At least locate someone who may live with the patient.
And don’t forget to do a beside glucose. We get a lot of hypoglycemics.
other professionals involved in elderly care, as well as family members are good resources to help an ER physician effectively manages these types of situations
By getting information from family members which includes calling them via telephone if they are not present in the ER.
attempt to contact caregivers and family to get more information.
Comprehensive and collateral history is vital
All above including EMR
All of above
nice
xx
Looking up previous visits/info and reading the EMS notes are important in guiding you to the patients true concerns. I also like to ask what is the MOST concerning issue today
all of above
old charts, family, ems
Reports from previous visits or admissions, documents brought with patient, call primary caregivers or family
getting family info
History and information from where/whom ever can provide.
read the old chart, try to get collateral info, talk up
definitely read the old records first
ask family members to be at bedside
call whomever the patient was in contact last to get details
give patients time to talk… a lot of patients required here
Collateral history is quite important
Ask for history from the patient and then the family members/ nursing home staff and compare differences and try to resolve them. Help out the patient with things I already know from their history (i.e. I don’t need them to list off all of their medication and past history because I have it from their GIM admission last month) to allow them to focus on the immediate problem.
contact family and family doc
For LTC patients I always like to follow up with the nursing staff as they know the patients well and can focus on in their acute change from their baseline.
i find most of the “decline in elders” i see in emerg involves an acute stressor on top of chronic frailty, made worse by the polypharmacy. getting is medication hx is quite difficult as pt’s never remember to bring their meds, and even if they do they have no clue which pills they’re taking how much.
i agree, often patient’s family and caregiver have lots to add for hx
Collateral info from family members. Review old chart. Good idea to call family doc.
when taking a history if open ended questions are confusing a patient, proceed with relevant yes/no questions.
That’s a really good observation. While open-ended questioning is usually a good idea, sometimes all you really need to know to proceed safely is specific information. But it’s important to have done enough of a cognitive screen to ensure that the closed-ended answer you’re getting can be trusted!
need to get full history from any possible source,EMR.GP,spouse,family,VON etc
In my institution we have now electronical documentation. one of the benefits of it is that we have access to a sumary of the patient Hx for those who has been in the hospital before. I usually read it first to collect information and also interacting with patients family. We also get a large number of patient coming from long term care facility so I usually read the transfer form.
“•Review old records FIRST (hospital chart, nursing home chart, ambulance record) – even before you see the patient. It’s probably the most efficient way of gathering a complete past medical history.”
Thank you! I’ve often been sent in to see patients before knowing a thing about them “because it’s good to learn how to take a history,” even when we’ve already been told they’re unconscious, delirious, or demented. It leads to a lot of wasted time and the need to come in to take two histories. Plus, I find it frustrates family members and patienrs who are getting asked the same basic questions for probably the third time by the time I see them.
Glad this is helpful! These are probably the most complex patients we see. Even if not unconscious, delirious, or demented, it’s unlikely that anyone would be able to give you all the details of a PMH that probably involves 3-5 chronic diseases, a few hospital admissions, a few surgeries, several consulting physicians, and a med list of 5-8 drugs! Would you? So yes it’s far better/efficient/helpful to gather as much objective verifiable data in advance as you can. And then limit the history-gathering to the really high-yield questions: “What’s new? What’s different? What has changed?”