2: Interview Basics Flashcards
Recite the opening remarks to a patient script
Hi! My name is student doctor Wiser.
I am working with your doctor today as part of your healthcare team.
I am here to collect some information on why you are here, perform an examination, and then report that information back to your doctor. Is that okay with you?
Before we begin, may I confirm your first and last name and DOB? How old does that make you? Thank you.
How would you like to be addressed?
What brings you in today?
Five steps in an interview
- Set the stage: welcoming patient and establishing comfort
- Elicit pt’s agenda, CC, and priorities
- Discuss pt concerns with open-ended questions
- Elicit details using direct questions
- Empathize and summarize
What level should pt educational material be printed in?
6th grade level
NURSE acronym for expressing empathy
Name: ID the underlying emotion
Understand: confirm that you understand by active listening
Respect: show that their reaction is important to you
Support: give a variety of resources
Explore: target questions to specifics of what a person shows interest in
SOAP Note stands for?
S: Subjective
O: Objective
A: Assessment
P: Plan
Nine parts of a subjective SOAP note
- CC
- HPI
- ROS
- PMH
- PSH
- Meds
- ALL
- FH
- SH
Objective part of SOAP note
Physical exam findings, labs, and imaging
Assessment part of SOAP note
What you think is going on with the patient; not always a diagnosis
Plan part of SOAP note
What you will do for the patient’s problem, including txs and OMT
Mnemonic for the HPI
OLDCAAARTS Onset Location Duration Character Alleviating factors Aggravating factors Associated symptoms Radiation Timing Severity
Three required questions for Meds + three things you must record about them
Ask about….
- Rx’s
- OTCs
- Supplements
Must record…
- Dose
- Timing
- Why the pt takes it
Three things required to ask about allergies + one thing you must record
Ask about…
- Medication allergies
- Environmental
- Food allergies
Must record…
1. Reaction
Mnemonic for Social History
FEDTACOSSSS Food Exercise Drugs Tobacco Alcohol Caffeine Occupation Spirituality Support Safety Sexual relationships
What is mandatory to ask for the Social History portion of Subjective SOAP note
Drugs, tobacco, alcohol + 2 additional sections
CDC exercise recommendations for adults and children
Adults: 150mins per week
Children: 60mins per day
Three questions to ask about drugs
- Quantity
- Frequency
- Route of administration
Two questions to ask about tobacco use
- Quantity
2. Duration
Two important screenings related to tobacco use
- AAA screening
2. Lung cancer screening
AAA screening
Recommended 1x screen for AAA in men 65-75 who have ever smoked
Lung cancer screening
Recommended low-dose CT for those 55-80 who have a 30 pack-year history and currently smoke or quit within the last 15 years
Pack years of smoking
Ppd x years = packyears
When do you use ppd vs packyears for tobacco use?
Current smoker: ppd for x years
If pt quit smoking: packyears
Two things to ask about alcohol use
- Quantity
2. Frequency
CAGE questionnaire
Screens pts who drink 1+ drink daily or lots on weekends -> can open door to convos about getting help
CAGE questionnaire questions
A. Has anyone suggested you Cut back?
B. Have you been Annoyed when people talk about your drinking?
C. Do you ever feel Guilty about drinking?
D. Do you ever need a drink in the morning to steady your nerves (an Eye opener)?
NIAAA Safe Drinking Limits for men and women
Women/pts over 65: 3 drinks in a day; no more than 7 drinks a week
Men: 4 drinks a day; no more than 14 drinks a week
Three questions to ask about caffeine intake
- Quantity
- Frequency
- What form
FICA mnemonic for asking about spirituality
F: faith and belief: do you consider yourself spiritual or religious?
I: importance: what importance does spirituality have in your life?
C: community: are you part of a spiritual community?
A: address in care: how would you like your healthcare team to address these aspects in your healthcare?
SAFE mnemonic for domestic violence
S: stress/safety
A: afraid/abused
F: friends/family
E: emergency plan
ROS vs associated symptoms
Associated symptoms: have to do with CC directly
ROS: can be anything in any other system; related or unrelated to CC
