The patient history is probably the most underrated aspect of a veterinary visit.

In many cases, you can learn just as much from the patient's history (if not more!) as you will learn from your physical exam.

In general, a good patient history includes the following information:

• Presenting complaint, which includes the duration and nature of clinical signs, client observations, etc.  
• Other health concerns, such as vomiting, diarrhea, coughing, sneezing, behavioral changes, etc. 
• General medical history, including chronic conditions and relevant previous illnesses 
• Current medications

While all of those factors are important, we all know that there’s more to a thorough patient history than simply filling in a list of questions. Consider these 5 tips to get the most out of your medical history.

1. Start with open-ended questions 

In veterinary medicine, being rushed is (unfortunately!) the norm. Many of us fear that if we give the client an opportunity to speak openly, they may talk forever! Therefore, we tend to jump in with closed-ended questions, trying to direct the flow of the conversation and be more efficient. 

A 2002 study attempted to look at just how long clients at an outpatient medical clinic would speak if they were allowed to talk without interruption.¹ The answer? Just 92 seconds. The mean talking time for medical patients was 92 seconds. Within two minutes, 78% of patients had finished their opening comments. Yes, there were a few patients who spoke for over five minutes, but only 0.06% of patients were included in this category. Most patients, if allowed to speak without interruption, will share for less than two minutes and then stop speaking. 

When you lead with an open-ended question and allow the client to tell their story, you accomplish several things. First, you give the client a chance to feel heard and increase their satisfaction with the visit. More important, however, you can quickly identify and zero in on relevant information. You are less likely to miss something important with this approach. 

Once the client has shared their story, you can begin to follow up with a combination of open and closed-ended questions. In general, the conversation should gradually narrow, opening with open-ended questions and closing with relevant closed-ended questions.

2. Listen carefully to the client 

As the client is sharing their story, you may be tempted to multi-task by beginning your exam or starting to type up your medical record. Resist that temptation!! Use active listening strategies, to show the owner that they have your full attention and to increase your ability to retain the information that the client is sharing. Avoid interrupting. When the client pauses, paraphrase parts of what they have told you to be sure that you understand correctly. Additionally, use nonverbal cues that indicate interest, such as eye contact, nodding, and open body language. If you need to jot down a couple of notes on key points of their story, feel free to do so… but make sure your primary emphasis is on listening, not note-taking.

3. Be careful when asking about current medications

In many cases, the question “is your pet on any medications?” elicits an automatic “no'' from the client. That doesn’t necessarily mean the pet is not on any medications! Clients often define the term “medication” differently than we do, which can lead to confusion and could lead you to prescribe a medication that places the pet at risk of a drug interaction. 

When asking clients about medications, be sure to clarify what you mean. Specifically ask the client whether their pet is currently receiving any over-the-counter medications, nutraceuticals, homeopathic supplements, or home remedies. Spending a bit of time on this conversation can significantly decrease your patient’s risk of drug interactions.

4. Ensure that your lifestyle information for the pet is accurate 

A pet’s wellness care recommendations are typically based on lifestyle. In many cases, relevant lifestyle factors are assessed once, at the initial visit, and the pet is forever vaccinated and administered parasite prevention based on this initial assessment. 

Realistically, we all know that lifestyles change over time. Indoor cats begin to go outdoors, or an owner moves to a new area and their outdoor cat begins to stay indoors. Stay-at-home dogs may begin to board more frequently and city dogs may begin taking weekend hikes with their owners. Don’t forget to ask about lifestyle factors at every visit, so that a pet’s preventive care routine can be updated if necessary.

5. Don’t forget to ask about behavior

Behavior problems are not just an annoyance for clients; they can lead to euthanasia or pet relinquishment. Therefore, it’s important for veterinary teams to be proactive in identifying and addressing behavioral concerns. If you wait for clients to become frustrated enough to seek your help, it may be too late to maximize your chances of a successful outcome. 

When obtaining your history, be sure to ask about behavioral concerns. You can begin with a simple intro question, such as “do you have any concerns about Penny’s behavior?” If possible, though, consider going into a bit more detail. You may ask a dog owner whether their dog is fully housetrained, friendly with strangers, and/or friendly with other dogs. Consider asking the owners of your feline patients whether their cat is using the litter box consistently, showing any destructive behaviors, or exhibiting any other behaviors of concern. Even if you don’t feel qualified to address behavioral concerns, identifying these issues will provide you with an opportunity to refer the client to a veterinary behaviorist or qualified trainer. 

While taking a medical history may seem like a relatively simple and straightforward process, it’s an important one. Think through the process consciously and give the client your undivided attention. By doing so, you can maximize the likelihood that you capture and address all relevant concerns, making the veterinary appointment more beneficial for both the client and the patient. 

Make sure to check out our eBook on what to do in the exam room. This checklist will ensure you don't miss a thing. 

References

1. Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ. 2002;325(7366):682-683. doi:10.1136/bmj.325.7366.682