Chapter 20 Patient Interview Learning Objectives Define the

Chapter 20 Patient Interview

Learning Objectives § Define the purpose and the key components of the patient interview § Identify effective strategies for interviewing the talkative patient and the quiet patient 2

Learning Objectives § Differentiate between closed questions, open-ended questions, and directive statements and give an example of each § List five obstacles to effective interviewing and discuss an effective alternative strategy for each 3

Learning Objectives § Describe techniques that may be used to help patients feel more comfortable discussing sensitive information § List the main components of the medical history 4

Learning Objectives § Conduct a patient interview to obtain a medical history § Accurately document the patient’s medical information on a history form 5

First Impressions § Medical professional’s role is to connect patient with physician or provider § Includes: checking vital signs and patient interview to obtain medical history § Use effective communication § Summarize interview when finished 6

Interviewing Techniques § Closed questions § Open-ended questions § Directive statements § Restating § § § Reflecting Redirecting Active listening Silence Summarizing 7

The Talkative Patient § Establish clear guidelines for the interview § May have to redirect patient to specific interview questions § Ask closed questions that require a “yes” or “no” answer § To ensure accuracy of information, restate the information § Redirect patient in kind, assertive manner 8

The Quiet Patient § Quiet or shy, provide little information § Ask open-ended questions that require more than one- or two-word answers § Practice wording questions ahead of time § Use directive statements 9

Obstacles to Effective Interviewing § Any medical provider other than a physician should refrain from offering medical advice § Do not provide false reassurance § Keep language and vocabulary professional and accurate § Speak in terms the patient can understand, do not use medical jargon § Take care not to imply judgment 10

Discussing Sensitive Topics § Personal information such as sexual activity, use of birth control, number of sexual partners, bowel and bladder function, and menstrual pattern § Provide privacy and patient comfort; allow patient to remain clothed § Assure information will remain confidential § Begin interview with general questions and end with more personal questions 11

Age-Appropriate Communication § Adapt vocabulary and interviewing strategies appropriate to age of patient § Children—sit at eye level to make eye contact § Older children and adolescents—offer choices whenever possible § Elderly—adapt for any sensory or perceptual deficits 12

The Medical History § Logistical data—DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings § PMH (past medical history)— immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries § FH (Family History)—information about parents, siblings, and children 13

The Medical History § SH (Social History)—patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol § ROS (Review of systems) —systematic collection of data regarding patient’s overall health 14

Documentation § Patient’s chart is a legal document § Documentation should be thorough, legible, and professional § Do not document in pencil, do not use unapproved abbreviations, do not add late entries, make corrections following facility’s policy guidelines, document facts, and do not make assumptions 15

Subjective Data § Known only by the patient § Patient must share information with the health team § Describe pain, nausea, emotional distress § Include patient’s own words; enclose in quotation marks § Patient states “I have a terrible headache” and “I feel like I’m going to throw up” 16

Objective Data § Obtain through observations by health team § Record data accurately § Use quantitative terms § Include physical examination findings, weight, vital signs, and test results 17

Subjective v. Objective § Patient has a 9/10 pain § Patient’s blood pressure is 120/80 § There is a two inch long incision above the patient’s umbilicus § There is purulent discharge coming from the incision § The patient is the sickest in the hospital § The patient has a fever of 102 F 18

Subjective v Objective § Patient feels weak § Patient fainted in the office § Patient Says he hasn’t been eating much lately § Patient thinks his headache is due to his high blood pressure § Patient’s pregnancy test results were negative 19

§ Subjective: what the patient says § Objective: what you observe. 20

Assessment § conclusion about the patient’s condition or diagnosis (may be done by physician) § Physician may list primary symptoms § May rule out (R/O) certain conditions 21

Plan of Care and Evaluation § describes how patient’s problem will be further evaluated and treated § May include diagnostic studies or treatments § Evaluation describes the patient’s understanding of the overall plan as well as his or her compliance with it 22

§ Melinda is a 22 year-old patient who has come to the clinic for the first time to establish care. She is quiet and sky and reluctant to disclose personal information. Her current chief complaint is pelvic discomfort and dysuria. You must obtain a complete health history, including information about sexual activity, birth control, menstrual pattern, and current symptoms. § Describe some strategies that might be employed to put this patient at ease and obtain the necessary data 23

§ Gloria is a 69 year old patient at the doctor’s office for her annual checkup. She is friendly, talkative woman who loves to tell stories and gets easily sidetracked. She has multiple medical complaints and is eager to discuss them all at great length. A complete health history and evaluation of current complaints must be evaluated in a timeeffective manner. § Describe strategies that might be used to keep this patient on track. 24