Health History Flashcards
Health History
Purpose
gather info educate re: health risks NEGOTIATE A PLAN what to do to ameliorate s/s where they are and how to move them forward offer counseling
Health and illness
Factors affecting
Social factors
Economic factors
Cultural factors—culturally defined
SZ either medical problem or demonic
Interview Rules
FOCUS ON PATIENT'S AGENDA
LISTEN MORE
*** will tell what is wrong and what they want
to do about it.
Talk less
Do not interruptInterview
Rule of 5 vowels
Audition- listen carefully Evaluation-sort relevant/irrelevant data Inquiry-probe areas for clarification Observation- non-verbal communication Understanding- be empathetic
Preparing for the Interview
Prepare Yourself
Appearnce,
Behavior
Nonverbal–posture, gestures, tone
Preparing for the Interview
Prepare the environment
Private
Comfortable/clean
Appropriate seating
Preparing for the Interview
Note taking
Jot down key items with few words
Maintain eye contact
Interview Techniques
Introduce yourself, WASH HANDS Explain role as student Use appropriate title to address patient Visitors? who are they and can they stay?
Interview Techniques
Invite pt's story use open ended questions f/u pt's lead with direct questions Use continuers--I see, yes, ok..... Confront to draw attention to statement or behavior
Interview Techniques
Interpretation
Reflection
Interpret patients behavior based on your understanding of the situation
echo or mirror what the patient is telling you
Interview techniques
Offer reassurance based on fact
Be empathetic–validate the patient’s feelings
Symptoms
What the patient feels/reports
Not absolute/subjective
Influenced by culture, intelligence, SEC
Signs
What the practitioner finds
Pain becomes a sign when elicited with palpation
Symptom Analysis
location quality quantity 0-10 chronology- timing setting precipitating & alleviating factors Associated manifestations- other s/s
Questioning to Avoid
Suggestive
Rapid fire
Do you feel pain in your left arm associated with your chest pain
Multiple questions at once
Questioning to Avoid
Leading (biased)
Medical Jargon
You haven’t used any illicit drugs, have you?
Communication Techniques
Transitions
Sexual health is really important so I am
going to ask some sexual health questions.
Facilitation- continuers
Confrontation, Interpretation, Reflection, Support
Format of History
Source and reliability
Chief Complaint
anything else you want to discuss
have all your questions been answered
Source is usually patient but could include family and friends; also nursing staff
Chief complaint -concerns causing seeking of medical attention
probe for underlying concerns–changes
underlying reasons for seeking health care
