Transcript: How to Get a Patient History - Nurse Practitioner Tips

​Liz Rohr:

Time management for new nurse practitioners, the struggle is certainly real. I made another video about time management in general, over here. But in this video, I really wanted to zero in on getting a patient history that's not only faster, but it's actually more accurate because when you do that, it actually saves you time. It also saves the patient time in terms of getting to the accurate diagnosis and treatment. It saves health healthcare dollars because you actually are more savvy with tests that you're choosing, the referrals you're choosing, and the treatments that you're choosing. So in this video I'm going to break down the way that I conducted my patient histories and the way that I recommend new nurse practitioners to do so. So if you're new here I'm Liz Rohr, from Real World NP. You're watching NP Practice Made Simple, the weekly video to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

So the first thing that I recommend is that you have a systematic approach. So I'm going to be peeking down at my screenings because I got a couple of notes here. But the first thing I recommend is that systematic approach of doing it the exact same way, every single time, as best you can. Right? Not being rigid about it but just having a general flow. Because when you do that, you eliminate the mental clutter that you get when you're like, "I'm not sure if I should ask that, if I asked that"... and you have to go back in the room a million times because you forgot to ask different questions, things like that. So if you would adopt a systematic approach, it really eliminates that. It also helps you deal with the other mental clutter that we have as new nurse practitioners.

The systematic approach that I recommend for symptoms specific visits, those like sick visits, and chronic care management visits that are very symptom specific is OLD CART. I've talked about this in a couple of videos, but I want to expand on this further and add some other things of course too, to help you really flesh this out and fill it out so that it can be the most useful for you. So OLD CART is the one that I recommend. Everyone has different things that it stands for. But what I mean is onset, location, duration, aggravating, or associated factors, characteristics, I forgot that one. Relieving factors, and treatment/time. So I'm going to go through each of them and add on the other things that I do to kind of weave that all together.

So if we're using an example of abdominal pain, the first thing that I say to every single patient is, "Okay, so when did it start?", like the onset? I want to pause here for a second to bring in my second biggest tip aside from using a systematic approach, which is options. I've talked about this a couple of times but specifically, you can apply this to basically any question that you ask a patient, because what happens is that unless they have something at the top of their mind ready to volunteer to you, they kind of look at you Like a deer in headlights. Because to them they're like, "Okay, so does she mean hours? Does she mean days? Does it matter if I say 10 or seven?" So if you say things like, "Okay, so when did it start? Days, weeks, months, years?" That immediately sets the stage of like, it doesn't have to be one year and 25 days, right? So it gives them an option of what you're looking for and also kind of like cuts down on the fact that it doesn't need to be that exact. Depends, right.

So that's one of the things that I recommend. So location this is branching off a little bit talking about differential diagnosis, but location is super important because I love anatomy based differential diagnoses. So if we're talking about abdominal pain, if we're talking about upper stomach pain, or epigastric pain, lower abdominal pain, right-sided left-sided, we'll definitely give you a sense of where to go with your differential diagnosis, and further with your history questions to be quite honest.

I want to pause there and say that as an experienced clinician, what I do and what I see other people doing... and you will get here is that you can actually start asking your history questions based off of the differentials that you have in mind. So as you develop in your practice if you have somebody with abdominal pain, you'll have those differentials in your mind and be able to ask the questions to help you parse down which direction to go. Talking about pertinent, positives, and negatives, which I kind of mentioned in that When to Use Antibiotics video. So onset location, duration: is it there all the time or does it come and go? Characteristics: is it burning, stabbing, aching? Things like that, pretty straightforward. Associated factors, so this is a huge pro-tip hack that I did as a nurse practitioner when I was new and also brought up recently by my friend Nurse Liz, on YouTube. If you don't follow her you definitely should if you don't follow her already.

But one of the things that I would struggle with is that I didn't have those differentials at the front of my mind, right. For chronic diarrhea for example. If somebody has abdominal pain with chronic diarrhea, I didn't necessarily know in the front of my mind that somebody with inflammatory bowel disease rather, you should really be asking about mucus and blood in their stool. Right? But that's okay, we all start there. Right? I talk about this and How to Make a Plan of Care video. So don't stress about that. Which I'll also link to down below this video. I got a lot of videos for you to watch if you haven't seen them already.

I recommend you choose the body system that you're asking about. So if somebody has abdominal pain, you're going into that ROS and asking the full thing, not just like nausea, vomiting. Like nausea, vomiting, diarrhea, constipation, blood in your stool, weight loss, like coffee ground stool, like et cetera, et cetera, all that stuff. So asking the entire ROS. And hopefully it's in your EHR which is right in front of you, if you use a laptop in the room. Otherwise, you can use a checklist of all the different questions you should ask. Then ask them about the associated factors you want to think about what are the associated body systems, right? So GI and GU you go together. So ask all the GU systems as well. Depending on the location of again, anatomy based differentials, if we're talking about epigastric pain, it could be your pulmonary system as well. Right? So you just want to think about that. You could ask all the ROS questions if you really wanted to. But anyway hopefully that will help kind of guide that.

The next one is relieving factors. I have some feelings about this one. So relieving factors, not only are you asking things what are they using to help with their symptoms right now? So "You have abdominal pain, that's epigastric, are you using... That's burning, are you using any antacids or things like that?" But also hyper important is that for some reason, patients typically in my experience have not automatically volunteered this. Maybe it's because I'm intimidating or the healthcare system is intimidating, I'm not sure. But if they've ever had this symptom before, or if they've gotten any treatment for it before.

So pausing on the abdominal pains example for a second, I had a patient a couple of years ago who had a little bit of cognitive impairment, which may have been part of this. But she was complaining of shoulder pain that radiated down from her shoulder to her wrist. I was like, I have no idea what this is. I dug, and I dug, and I dug, and I asked all the questions. I excused myself, I looked at things on UpToDate, and I asked more history questions. I came up with a plan of care and I was like, "You know what? I think you have really bad carpal tunnel." I was so proud of myself was such a beautiful diagnosis because of FYI that can happen, it's so bad that it radiates up to their shoulder.

I'm talking about bracing, and injections, and she might need surgery and all this stuff. She interrupts me and she's like, "Oh, Liz. Yeah. I saw my orthopedic yesterday. He said, I might need another surgery." I just was like, "Okay." That was not the only time that's happened and it probably won't be... Again, I'm pretty good about asking that now, but just always ask, right? Because people don't necessarily think to volunteer. Going back to the abdominal pain example, if they have burning epigastric pain with some weight loss, did they get H. pylori treatment last year and they never came back for retesting, or they needed an endoscopy and they didn't go. Right? So that tells you a lot of information. So always ask about the previous treatment that they've had.

Two to three other things I want to say. So one other way to think about it... and then you could also ask this as a question. Is that what you're trying to get to getting a history is what does this actually look like in their life? Right? Because if you had somebody with epigastric pain, epigastric abdominal pain, you might right away think about, "Oh, okay, here are all the labs I want to do. I want to do an ab CT. I want to do an ultrasound. I want to do blah, blah, blah, blah, blah." Right? Versus if you kind of step back, think about like, what does it actually look like in their life? Then you can kind of figure out like, "Oh, okay, this sounds a little bit more like a gastritis, or a heartburn without any red flags. Maybe we'll try some PPIs before we do this whole fancy workup or these fancy labs, like et cetera, et cetera." Right?

So you don't necessarily have to ask, "Well what does this look like in your daily life?" Because they might give you that deer in the headlights look of like, "What are you talking about?" Say things like, "Okay, so what does this look like for you? Do you wake up with the abdominal pain? Do you have pain between meals? Is it only with meals? Is it only with certain foods? Is it at night time?" Things like that. So trying to like paint a picture in your mind of what it looks like. So you can further investigate like, "Is this pancreatic cancer or is it like gastritis?" You know what I mean? Two other things.

There's one about tone and speed. I want to give you permission that you are the captain in this scenario. Because ultimately patients are responsible for their health, and they're in charge of their own life, and they get to make decisions about what they do, of course, which I celebrate and I respect. However, you need to know that in this role as nurse practitioner they're coming to you for help and you are the expert. It's okay for you to redirect and to ask questions. So if you ask questions like "When did this start?" and you get into kind of a non-answer or an answer that goes off and it isn't really appropriate to the other OLD CART questions. Because it might be right? They might fill you in with the other OLD CART questions. But if they don't, it's okay to bring them back. Politely interrupting and redirecting and asking the question again. Sometimes I have to ask the question three times. "Oh, but actually, when did it start? Can you tell me specifically when it started? Can you tell me in days, weeks?" You know kind of like clarifying in different ways, right?

Then the other one is when you kind of go in with that directed options based speed and tone, it tends to make it flow better. You get better information and you can help them better. Right? So I want to give you permission and empower you to do that because sometimes we do need to do that. It's important to make sure that it's not just them feeling heard because that's incredibly important. You might feel like you're interrupting them and then they don't feel like they're getting good care. It's actually the opposite in some ways, because if you don't get all the information that you need, you're not helping them. Then also if you do this repeatedly and you're getting yourself burnt out, because you can't ever get your work done that's not helping them either. Because if you can't be a nurse practitioner, you can't help them. Right?

I say this a bunch because speaking from experience, but also just, it's super, super common. The last thing I want to say, and I'll kind of recap all the points that I made here is that we really want to do things in a very nonjudgmental way. That gives us the most accurate information. So you may not agree with me, but I feel like what our role is to gather data, factual information, figure out the differential, diagnoses the plans of care and give advice of medical treatment based off of the information that we're given. So it's not necessarily our place to make judgements about the use of illicit substances, or alcohol, or the way they, they take their medications, or the sexual partners they have, or the sexual practices that they're engaging in, things like that. Because when we have those, we don't get the information that we need.

Really again, it comes back to data, and using data to inform the clinical picture, to inform the medical advice, right. Giving options is really helpful but also when we give the options that patients may themselves consider to be unacceptable, right? So medication adherence, right? Not assuming that they take their medications, that they know what the names of their medications are, and that they know what their diagnoses are. Giving them the out of being like, "Yeah I don't take my meds. I don't know what I'm supposed to be taking. I don't want to take them. I only take them three times a week." Things like that.

Because if you decide to change their plan of care... I literally did this the other day, which is embarrassing to admit. But I had somebody who had cirrhosis, who I was assuming was familiar with her medications and I was trying to make medication changes. When she came back and answered me she seemed like we were having a fluid conversation where she understood what was going on. Then she said something that just made me feel like, "Oh, I don't think we're quite on the same page." It kind of like reeled me back in. We just really simplified it and just did one thing at a time. I had her come back a lot sooner and get case management. Because patients don't necessarily know that they have cirrhosis and that they need to take lactulose and furosemide and what that means. They might not be able to read. Right?

So anyway, if you open up things in that nonjudgmental way, you'll get more information. Versus if I just sent another medicine to the pharmacy without collecting that data, she wouldn't necessarily pick it up, number one. She may pick it up and start taking it, but then she's not taking her other things. You get the picture there. So just to recap, picking a system that works for you, using it consistently. Asking things in a nonjudgmental way. Setting the tone and redirecting to ask your questions as appropriate, because that's how you best help people. Thinking about how it looks in their daily life. What treatments they've already done before, and giving options. Absolutely, always giving options. Not necessarily leading them, but giving them the options to choose from.

So did you like this video? If so hit, like and subscribe and share with your NP friends so together we can reach as many new nurse practitioners as possible to help make their practice a little bit easier. I'd love to hear from you. If you want to leave a comment down below of something you can take to your practice, or other things that you do to get a really accurate health history from patients, I'd really love to hear it and so would your colleagues. If you haven't grabbed your Ultimate Resource Guide For the New NP, you can go grab a copy at realworldnp.com. You'll get these videos sent straight to your inbox every week with notes from me, patient stories, and bonuses. But I really just don't share anywhere else. Thank you so much for watching, hang in there, and I'll see you soon.