Clinical history taking is one of the essential skills of a pharmacist, and it’s something a lot of us are actually exposed to in the MPharm. However, there’s not a huge emphasis on the actual act, more the theory and requirements. As a result, it can be extremely daunting to take a history – especially when your patient is on a plethora of meds!
I took my first drug history as a “baby pharmacist”: a third-year pre-registration pharmacist
in a local Trust. Much like other pre-registration and now trainee pharmacists, my journey
began in the medical admissions unit, where patient turnover is so high that you should be an expert on history taking in a week.
Reader, that was not the case.
At the time, I shadowed and was trained by three very different pharmacists, with three
very different approaches. One was (for lack of a better word) a bit flappy but had so many decades of experience behind her that her process was buried deep in her practice. Another was laid back and not so systematic, but taught me the difference between the levels of review, and reassured me that I’d pick it up soon.
Reader, that was not the case.
Finally, I went up with my very brilliant tutor and she, being a relatively newly-qualified
pharmacist, showed me how to carry out a history, how to get it really accurate, and told
me the biggest secret: a hospital pharmacy technician is the best person to learn this skill
from. On the ward, pharmacy technicians have multiple roles: taking drug histories, some account for quantities of patients’ own drugs, ensuring stock levels are maintained throughout the hospital. They are brilliant at all of this.
A few WEEKS into my rotation, I worked with a technician who spent the morning showing me the best way to take a history and boom. I was away. Never looked back except to say
“thank you”.
Fast forward five years, and I’m using those skills in pre-assessment clinics and consultations regarding post-operative pain.
Pharmacists in the community are increasingly taking clinical histories of patients recently discharged from hospital, or those whose clinical situations have changed. Clinical history
taking is an area of practice we must be confident and expressly competent in.
To prevent you from falling into the same depths of confusion, let me share with you my
five top tips for taking a clinical history:
1. Outline a process for yourself. It’s clearly best to start with the presenting complaint and
details about it, but what then? You need to understand the patient’s co-morbidities, their
drug history, social history, their family history in relation to their presenting complaint, and review any associated symptoms. You may opt to do a “head-to-toe” approach, where you assess the patient downwards. You may opt for an approach that starts at the presenting complaint and moves outwards into the larger context of the person’s history. You may stick to the order I listed them in, which is much more traditional, and there’s nothing wrong with that!
2. Use multiple sources. Yes, your patient is usually the best source of information, but you need an accurate history to be able to get them the best management plan possible. Have a look at their summary care record, their repeat slips, their past letters and journal entries. Build yourself the journey of the patient so nothing is missed.
3. It’s not all about today. Unless it’s a rather acute presentation, symptoms tend not to
spring up on the day of the consultation, so you need to understand the context.
Go back as far as when the person noticed the symptoms and then a bit further back – can you establish a correlation or cause for the presentation?
4. Be precise. This is not only because your patient deserves a healthcare professional who will have as much information as possible that they can adequately help them, but it will be of great use in the future. Other healthcare professionals rely on our history taking, and if you write “Had antibiotics, no change”, they’re not going to thank you, and neither will your patient.
5. Ask questions. This is both the most obvious and the most important of the tips we’ve
shared today. Have you extracted as much relevant information as is plausible? No? Time to ask another question. If your patient presents with abdominal pain, you’re not going to give them a prescription for omeprazole and paracetamol, are you? You’d ask them when it started, where it is specifically, what makes it worse, what makes it better, and if they’ve
already tried anything for it. Asking questions is a brilliant skill, and it’s one that will always
be improved. Go forth and be excellent history takers! Never be afraid to admit you need to look something up, or confer with a colleague – one of our patients said he had compartment syndrome and I had to dip out for a quick google, but that’s fine! (Yes, I expect you to google it yourself too)
The APCG course on Minor Illnesses will cover clinical history taking, and you’ll be learning from the experts in their fields, namely Dr Yassir Javaid, who has 22 years’ experience of practicing medicine and 18 years’ clinical experience in General Practice.
Don’t miss out on this opportunity, and book now at
See you there!