Module 4

HISTORY TAKING

&
RISK ASSESSMENT

OBJECTIVES: MODULE 4
1.

To get an overview of the module and learning objectives List the goals of history taking of STI/RTI clients Identify the information and skills necessary for accurate history taking

2. 3.

4.

Define risk assessment and explain its use in STI/RTI prevention and limitations in STI/RTI management
Demonstrate history taking and risk assessment using a standardized checklist
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5.

GOALS OF HISTORY TAKING FOR RTIs/STIs

1.
2.

Make an accurate and efficient syndromic diagnosis.

Establish the clients risk of transmitting and contracting STIs/RTIs. Find out about partners who may have been infected.

3.

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PREREQUISITES OF GOOD HISTORY TAKING

1. Privacy and confidentiality. 2. Rapport building. 3. Good verbal and non-verbal communication skills. 4. Unbiased / non-judgmental attitude of provider.

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PRIVACY & CONFIDENTIALITY

1. 2.

Raise physical barriers for auditory and visual privacy. Bring the privacy to notice of client to build confidence. Assure confidentiality verbally.

3.

4.
5.

Ensure confidentiality in record keeping.

Ensure confidentiality during referrals to others and lab.

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RAPPORT-BUILDING AND CLIENT-FRIENDLY APPROACH

1. 2.

3.
4. 5.

6.
7.

Smile and use welcoming tone of voice. Introduce yourself. Use clients name, if you know. Offer client a seat. Begin when you have privacy. Make eye contact, if culturally appropriate. Be respectful and understanding, especially if the client is hesitant or reluctant to speak.
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NON-VERBAL SKILLS

1. 2.

Maintain eye contact. Practice active listening.

3.
4.

Maintain expression of enthusiasm.

Reflect clients behaviour.

5.

Stay close to the client.

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VERBAL SKILLS
1. 2. 3. 4.

5.
6. 7. 8. 9.

Use open and close-ended questions. Always phrase your questions respectfully and politely, even if you busy or rushed. Use language that client knows well. Avoid using medical jargon. Ask one question at a time. Keep your questions free of moral judgment. Show empathy. Avoid using leading questions. Ask clients permission before asking personal questions related to sexual issues.
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STEPS OF HISTORY TAKING

1.

General information.

2.
3.

History of presenting illness.

Past medical history.

4.

Sexual history.

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GENERAL INFORMATION

1.
2. 3.

Name
Age / Sex Occupation

4.
5.

Marital status
Number of children

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HISTORY OF PRESENT ILLNESS: MEN

Symptoms. 2. Duration. 3. Men:
1.

1. Painful/painless (bubos - associated with ulcers / not scrotal swelling). 2. Painful urination (urethral discharge). 3. History of trauma (scrotal swelling). 4. Ulcer Painful? Recurrent? Appearance? Spontaneous onset?. 5. Other symptoms itching or discomfort.
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HISTORY OF PRESENT ILLNESS: WOMEN

1. 2. 3. 4.

Painful urination and frequency (vaginal discharge). Vaginal bleeding. Painful or difficult pregnancy or childbirth. Painful or difficult menstrual periods.

5.
6.

Missed or overdue period.

If ulcer Recurrent? Painful? Appearance? Spontaneous onset?.

7.

Other symptoms itching or discomfort.

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MEDICAL HISTORY
1.

Any past STIs? : Type? Dates? Any treatment / response? Results of test?. Other illness: Type? Dates? Any treatment/response? Results of test?. Medication being taken currently. Drug allergies.

2.

3. 4.

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SEXUAL HISTORY
1. 2. 3.

Use of contraceptives, if any. Menstrual and obstetric history. Currently active sexually? If yes, number of current partners.

4.
5.

New partners in last 3 months.

Risky sexual and other behaviour.

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RISK ASSESSMENT

Risk assessment is a process of confidentially asking

a patient particular questions to determine his or her chance of contracting or transmitting a STI/RTI (e.g. many women may be at risk due to the behavior of their husbands or partners).

If A = B = C, then A = C
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RISK ASSESSMENT: WHY?

1. 2. 3. 4.

To determine STI/RTI treatment. To tailor patient education messages. To determine need for lab test. To determine need for specific referrals (ICTC).

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WHAT PUTS PEOPLE AT RISK?

1.
2. 3. 4. 5.

Occupation: Sex worker, bar girl, truck driver.

Migration / long stays away from home. Known history of STIs/RTIs. Partner has history of STIs. Problems during pregnancy.

6.

Have casual partners.

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CHALLENGES IN RISK ASSESSMENT

1. 2.

Sensitive process. Embarrassment due to personal questions.

3.
4.

May get inaccurate information.

Client may not understand the question and its importance.

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MAKING BETTER RISK ASSESSMENTS

1. 2.

Ensure privacy and confidentiality. Tailor questions according to local needs.

3.

Put questions according to local culture and sensitivities.

Explain to clients why the process is important and may affect diagnosis, treatment and advice.

4.

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ROLE PLAY
Open the checklist for history taking Observe the role play carefully Note which steps are followed Be ready to share one thing you liked during the role

play
One step that you would have done differently

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TO SUM UP
1.

2. 3.

4.
5.

Goal of history is to get information for good diagnosis and treatment, establish risk and provide tailor-made advice. Sexual history is an essential component of history taking. Make yourself and your client comfortable during risk assessment. Good communication skills are paramount for history taking and risk assessment. Risk assessment provides you important cues for appropriate treatment and prevention.
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THANK YOU ALL

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