Medical interviewing serves as the cornerstone for the performance of medical evaluations and the formulation of treatment plans. The patient’s medical history serves as the background and context within which the presenting clinical complaints have arisen. When undertaken in a thorough and comprehensive fashion, the history provides a rich source of clinical information that can be of major assistance in the diagnosis and treatment of medical, surgical, and psychiatric conditions. The medical interview and history, correlated with findings on examination, assist with the diagnostic process and often serve as the primary factor in the formulation of directions for further clinical workup. This combined information is also useful for following a patient’s clinical response to treatment.

The format of medical interviewing and general medical history taking is directly applicable to evaluations occurring in emergency departments and in forensic contexts. The overall format includes documentation of the patient’s clinical complaint, usually in his or her own language, followed by a history of present illness, a review of medical history, family and social history, and a review of systems. An overview of general medical interviewing and history taking appears in Table 3.1. This structure is always useful as the basic outline for case assessment, documentation, and case presentation in emergency departments and all other clinical/medical settings. It serves as a structured approach to data gathering, focusing on a chief complaint for the purposes of diagnosis and treatment. It is also useful for documentation in medicolegal contexts. In the clinical/medical context, clear and structured documentation is useful to carry out the essential function of medical records—serving as a communications device that summarizes clinically relevant information that permits subsequent caregivers, who may not have direct contact with one another, to collaborate efficiently and effectively. In a medicolegal context, structured, thorough documentation is useful for the documentation of clinical presentation, diagnosis, and management; demonstration explicitly or implicitly of the rationale underlying clinical conclusions and diagnoses; and the recording of therapeutic interventions undertaken in response to the clinical conclusions and diagnoses, as well as the patient’s response to them.

Medical interviewing or history taking in an emergency department is essentially the same as general medical interviewing and history taking, except that it is more focused on the chief complaint and the patient’s immediate needs for evaluation and treatment. Documentation tends to focus primarily on pertinent positives and negatives, both historically and on examination. The interview and documentation are oriented around an evaluation of the patient’s urgent clinical needs and the initiation of lifesaving and/or immediate appropriate treatment. An additional purpose is triage of patients for referral for outpatient follow-up or subspecialty evaluation and further treatment. Clinical/medical documentation in the emergency department is essential for communication about
the patient’s chief complaint, pertinent history, and clinical presentation to subsequent clinicians for the purpose of facilitating further evaluation and management. These clinicians either function as part of the emergency care team or provide care for the patient following treatment and release from the emergency department. Medicolegally, the emergency department record is a useful retrospective source of information that summarizes the patient’s history and clinical presentation, the diagnoses or conclusions drawn about the patient, and the treatment initiated or triage undertaken for further evaluation and follow-up. Retrospective medicolegal assessment of the record often focuses on the conclusions drawn, the treatment provided, and the rationale for both and seeks to legally establish “facts” based on what is documented in the record. It also allows assessment of the appropriateness of clinical conclusions drawn and of subsequent treatment sought by the patient after emergency department evaluation.

Forensic medical interviewing/history taking is essentially the same as general medical interviewing/history taking. It includes the consideration of clinical and legal issues defined by the context in which the interview or history is taken and the nature of the legal issues being considered. Such interviewing and history taking has a variety of purposes, such as evaluating the patient’s clinical presentation; arriving at a diagnosis or an explanation of the presentation; recommending treatment; establishing a record of the evaluation and the conclusions drawn as future evidence, which may be useful in a legal proceeding; and preserving observations and findings for future reference in legal contexts.

Perhaps the most significant difference between forensic medical interviewing/history taking and general medical or emergency medical interviewing/history taking is the attention to documentation that is necessary. The documentation must be as objective and detailed as possible, including observations of and conversations with the patient. It should be primarily data oriented and include only those conclusions or explanations that are based soundly on the data collected both historically and clinically. Forensic medical records should also be written in a way that avoids rendering legal conclusions or definitive opinions that are the province of a legal fact finder. The clinician should thoroughly document the patient’s history, general observations of the patient, and the results of the clinical examination. The clinician can draw clinical conclusions and can express an opinion that those conclusions are consistent with a particular cause, without arriving at a conclusion with factual certainty. This approach allows the cause to be determined factually in a legal context later, following consideration of all the evidence, which is often not known or understood by the clinician at the time of the evaluation. The clinician may also make appropriate referrals for follow-up treatment and other support services based on clinical conclusions consistent with a particular cause, without arriving at a definitive conclusion about the cause of the clinical presentation.

Treating patients in emergency departments often involves an evaluation of clinical complaints that have medicolegal significance, either at the time of presentation or later. Most patients who present as victims of violence or abuse have immediate medicolegal involvement, and patients who were injured in accidents may be involved in subsequent litigation focusing on the injuries they sustained. Therefore, a large proportion of cases seen in emergency departments may ultimately have medicolegal significance. Preparation of the emergency department record with an awareness of its medicolegal significance may be extremely helpful to the patient, who may be involved in litigation later, and to the clinician, who may be called on to testify retrospectively and who may need to rely on the record as the primary source of information during the testimony. Frequently, this testimony is requested after a significant time has passed since the emergency visit.

Although there may appear to be tension between the necessity to evaluate, treat, and triage patients in an emergency department and to document that process efficiently and the necessity to generate a comprehensive and informative medical record for medicolegal purposes, the two necessities are not incompatible. The approach to documentation must be flexible enough to permit the addition of more extensive information when it is both clinically and medicolegally indicated. In this manner, the patient’s narrative and/or the clinician’s observations of the patient’s demeanor and behavior, and other potentially relevant medicolegal information, can be included in the emergency department documentation to assist a fact finder in assessing the clinical presentation and determining its cause in subsequent legal proceedings.

Underlying the process of performing clinical interviews and obtaining medical histories are interview techniques oriented to eliciting information from the patient for the purposes of diagnosis, treatment, and medicolegal documentation. Generally, medical interviewing techniques commence with open-ended or broad questioning and proceed to more focused or narrower questioning. The clinician attempts to elicit the patient’s history in the patient’s own narrative, which is very useful in the clinical evaluation of the presenting complaint and especially helpful in forensic contexts. Some patients are not communicative, for a variety of reasons, so the clinical history must be obtained from collateral sources. Those sources should be documented in the record in terms of both identity and content. If a patient is not communicative about his or her own history, the record should reflect that fact and should contain observations of the patient and an assessment of any clinical reasons for the inability to communicate. Furthermore, if the patient is conscious and alert but not communicative, collateral history is most appropriately obtained outside the patient’s presence and documented as such to reduce the possibility that any subsequent communication by the patient was prompted or suggested by the collateral source. This is especially necessary if the patient is an awake but reticent or mute young child who may be developmentally susceptible to prompting, which can result in an inaccurate history.

A mental status examination or Cognitive capability screening examination cognitive capacity screening examination should be done as part of the assessment of the potential clinical reasons for the patient’s uncommunicativeness. These exams may also have clinical importance for the assessment of the patient’s clinical presentation, diagnosis, and initiation of further workup, or appropriate treatment. When evaluating noncommunicative patients, observations of their behavior must be documented as thoroughly as possible. Such patients may never provide information regarding their history or circumstances, so behavioral observations and clinical findings documented in the record may be all that will be available for clinical evaluation and treatment and for future use in medicolegal contexts.

Victims of violence and abuse represent a variable but significant percentage of the patients who present to physicians’ offices and emergency departments for clinical evaluation. As many as 3 million children have been reported to state agencies as victims of child abuse or neglect in single calendar years and approximately 900,000 of those referrals are substantiated (1). Approximately 10% to 15% of cases of child abuse are first reported by medical care providers (2).

Victims of violence and abuse presenting to emergency departments can be divided into four categories by age and by virtue of whether they are directly and reliably communicative: child noncommunicative, child communicative, adult noncommunicative, adult communicative. For communicative individuals, both children and adults, interviewing and history taking are largely based on the patient’s narrative. Very young children (younger than 4 or 5 years) represent a special population whose narratives may not be credible or reliable. The narratives of very young children should be recorded and documented; however, historical information may also need to be derived from collateral sources, outside the presence of the child, to evaluate the young child’s presenting complaint more thoroughly. For noncommunicative patients, information must be obtained from collateral sources. These sources should be identified in the record, along with careful observations of the patient and thorough documentation of the results of mental status or cognitive capacity screening examination for noncommunicativeness.

Interviewing or obtaining a medical history from a communicative child relies largely on the patient’s own description of his or her history and chief presenting complaints. A potentially significant issue when talking with a child is assessing credibility and reliability. Although definitions of child competency, as contained in statute and case law, vary somewhat among jurisdictions, reference to a general definition may be beneficial. Generally, competency consists of the ability to understand and answer questions intelligently and accurately; to provide truthful versions of an experience; and to understand the difference between right and wrong and truth and falsehood. Studies of child credibility focus on the influence of childhood development, on the content of the information provided, on the relationship
between the content and the context in which the event occurred, and on subsequent statements about the event (3). One measure of a child’s credibility is the stability of information provided and its unchanging nature over time. The stability of information must be placed in the psychological context of the child who provides it (4). In a study of children receiving therapy for sexual abuse, 75% initially denied the abuse and 22% recanted previous disclosures, whereas other studies indicate that most children maintain their claims of abuse and never deny them to officials once they are questioned (5). One clinically observed pattern of disclosure is that the child is initially silent, but allegations emerge once an adult becomes suspicious and questions the child. Upon questioning, the child may at first deny the allegations, but he or she subsequently discloses details because of weariness of the abuse or fear that something worse may happen. However, children will often not disclose the information because of shame, fear, or embarrassment or because they do not want to get into trouble (6).