Obtaining an effective history requires 5 core skills:
- Open- and closed-ended questioning. Start with open-ended questions to obtain details on the presenting complaint in the owner’s own words, then progress to more focused closed-ended questions to clarify details (eg, duration, frequency [Table]).
- Reflective listening. Paraphrase parts of the owner’s story while allowing the owner to add further information, clarify points, and correct misconceptions. Reflective listening confirms the veterinarian’s desire to understand what the owner is saying. Reflective listening can also provide opportunities for the veterinarian to voice his or her interpretation of the owner’s feelings.
- Pausing. Avoid interrupting the owner’s story.
- Positive nonverbal communication. Use gestures such as eye contact, head nodding, and open body posture to encourage the owner to tell his or her story.
- Empathy. Use empathic statements (eg, “It sounds like you did all that you could for Leo.”) to build trust and rapport and show the owner that he or she is being understood and heard. Empathic statements can help obtain better diagnostic information and encourage adherence to treatment, resulting in a more positive outcome.
Good organizational skills are essential to ensuring the patient’s history is obtained clearly and efficiently. Use of an interview template can ensure no questions are missed and facilitate capturing the information in the medical record (See Medical Record Form).