Health Assessment Ch. 2- The Interview & Health History Flashcards
5 reasons to obtain an interview
a. get or give information
b. identify a problem
c. evaluate change
d. teach
e. provide support pr counseling
3 phases of an interview
a. introductory: introduce and explain role, “establish trust”
b. working phase: reason for seeking care, “chief complaint”
c. summarization: closing, questions
Types of Nonverbal communication
a. professional appearance
b. body language
c. facial expressions
d. eye contact
e. gestures
f. tone of voice
g. sounds such as crying or moaning
2 types of communication used during an interview
a. non-verbal
b. verbal
Holistic Communication
Be CLEAR (C)enter yourself (L)isten wholeheartedly (E)mpathize (A)ttention (R)espect
Effective Verbal Communication Strategies**
a. active listening
b. active observing
c. open-ended questions
d. clarification
e. confrontation
f. empathy
g. respect
h. exploring
i. facilitation
j. focusing
k. reflecting/stating the observed
l. transitional statements
m. silence
n. summarizing
Verbal Communication to avoid
a. leading the patient
b. asking too many questions
c. not allowing enough response time
d. using medical jargon
e. assuming what the patient is saying
f. taking the patient’s responses personally
g. using cliches
h. specifically asking “why” questions
i. offering false reassurance
j. changing the subject inappropriately
k. giving opinions
l. stereotyping
m. using patronizing language
Tips for communicating (hearing impaired)
a. make sure hearing aids are on
b. make sure batteries work
c. reduce background noise
d. face patient, speak slowly & clearly
e. written communication
Tips for communicating (visually impaired)
a. ask patient how much they can see
b. always ask permission before touch/ allow them to touch you
c. describe layout of room
d. tell patient before you leave room
Tips for communicating (aphasiac patients)
a. quiet environment
b. allow extra time
c. one question at a time
d. speak slowly & clearly
e. be honest
Tips for communicating (cognitively impaired)
a. use simple questions
b. sit directly in front of patient
c. maintain eye contact
d. speak slowly & clearly
e. may need to communicate with secondary source
Tips for communicating (aggressive patients)
a. be calm, reassuring, and empathetic
b. never argue
c. acknowledge frustration
d. reassure confidentiality and safety
e. be alert and sensitive to nonverbal communication
f. always have a clear pathway out
Tips for communicating (language barrier)
a. ask what is preferred language
b. interpreter
c. simple & clear questions
d. allow more time
e. DO NOT use family member/friend
Tips for communicating (low health literacy)
a. speak in simple language
b. use illustrations
c. allow more time
List Biographical Data
a. age
b. gender
c. address
d. etc
Chief Complaint
reason for seeking care
-always write in quotation marks
History of Present Illness (OLDCARTS)
(O)nset (L)ocation (D)uration (C)haracteristics (A)ggravating factors (R)elated symptoms (T)reatment (S)everity
Medications
ask patients about ALL medications they are currently taking including:
a. prescription
b. over-the-counter (OTC)
c. vitamins
d. herbal supplements
Immunizations
see CDC Immunization Schedule
https://www.cdc.gov/vaccines/schedules/index.html
Past History
a. childhood like illnesses (measles, chicken pox, rheumatic fever)
b. adult like illnesses (diabetes, hypertension, cancer)
c. accidents or injuries
d. hospitalizations
e. surgeries
f. metal illnesses
4 topics included in psychosocial assessments
a. behavioral
b. environmental
d. social
e. financial/economic
Domestic Violence Questionnaire**
HITS
Substance Abuse Questionnaires**
CAGE AID & TICS
Functional Assessment
assesses a patient’s ability to perform activities of daily living (ADLs)
Spiritual Assessment Tool**
FICA
Review of systems
a. report or deny symptoms
b. general status
c. skin, hair on body, nails
d. head, eyes, ears
e. nose and sinuses, mouth and throat, neck
h. respiratory
i. breasts, women’s health, urinary, male genital
j. cardiac, hematological, gastrointestinal, musculoskeletal, neurological
k. obstetrical history
l. peripheral vascular
Mental Health Assessment
a. general survey/ appearance
b. emotional reaction
c. speech pattern
d. memory/cognition
e. behavior and mood
f. suicide assessment
Cognitive Assessment (pg.39) 3.5
mental state examination
5 areas of Cognitive Fucnction
a. orientation
b. registration
c. attention & calculation
d. recall
e. language
