Interviews Flashcards
comprehensive health history
done for new patients, creates a database, opens dialogue, Begin clinician-patient relationship
Establishes a baseline
Identifies weaknesses and strengths in the patient’s approach to health maintenance and wants to know everything. ex. coffee, smoking vs. water intake
focused assessment
For established patients ex. routine, urgent care visits or follow up (f/u) visits Often limited to a specific body system Are “ problem- oriented” For chronic problems, focus on what you have been doing and how are you coping recently: Self-management, Status of the problem(s) Patient’s functional capacity
when do you a comprehensive vs. focused exam?
Depends on:
Magnitude and severity of the patient’s problems
The clinical setting (inpatient or outpatient, primary or subspecialty care)
Time available
If possible review old medical records and/or today’s prior notes before seeing the patient
What does SOAP stand for?
Subjective – by self report Objective - observable findings (physical exam, diagnostic info (lab, imaging, etc.) Assessment Plan SOAP format – used for some charting
Health History Format
a structured framework for organizing information in written or verbal form to establish a record of the encounter. if unable to receive put poor historian or use family and the source
Interview Process
requires effective communication and relational skills, including the ability to respond to the patient’s feelings and concerns
Name the 9 Components of the Comprehensive Adult Health History
Identifying data, source (do not use family if not English speaking) and reliability Chief complaint (CC) History of Present Illness (HPI) Medications, Allergies, Lifestyle Habits Past Medical History Health Maintenance (PMH and HM can be put together must include surgical history) Family History Personal Habits and Social History Review of Systems (ROS)
Identifying data, source and reliability
Date and Time – always included
Identifying Data – name (initials only), age (DOB), gender, marital status
Source of the history – patient, family, friend, medical record who is most reliable
Source of referral – for consults and specialty care
Reliability – varies according to the patient’s memory, trust, and mood. Judgment is usually made at the end of the interview.
Chief Complaint
The one or more symptoms or concerns causing the patient to seek care. what is most pressing
Examples: Abdominal pain, Fatigue, Injury, Cough
Documented as: “Reason for visit”, often include duration
Examples: “sore throat X 2 days”; “fatigue X 3 months”; “ankle injury yesterday”
Use patient’s own words when possible
*not all visits have chief complaint annual PE, college PE, camp physical, bus driver physical, sports physical
History of Present Illness
A complete, clear, and chronological account
Patient’s responses and the effects the problem has had (ex. unable to do things because of problem aka grocery)
From the patient (or document the source)
You must organize the information
the Sacred Seven as well as pertinent positives and negatives (symptoms gather info not organized upon obtained but create
chronological story, documenting source)
sacred seven
Location Quality Severity Timing Setting Aggravating or alleviating factors Associated symptoms
go through each for each relevant important system
different mnemonics
There are different mnemonics associated with this: OPQRST (O = onset, P = palliative, provocative, Q = quality, R = radiation, S = site (location), T = timing OLD CARTS (O = onset, L = location, D = duration, C = character, A = alleviating and aggravating factors, R = radiation, T = timing)
Location
Location: precise location, deep or superficial, specific or diffuse
“Where do you feel it?”
“Point to me where you where you feel it.”
“Does it radiate (spread) draw it?”
Quality
usual descriptors for symptom
example: pain (aching, burning, sharp, dull)
unusual descriptors (often associated with psychological problems)
“What is it (symptom) like?”
“Can you describe it (to me)?”
most times people have difficulty describing it using words to describe
Severity
intensity, impairment or disability, number of events, size
“How bad is it?”
“ On a scale of 1 to 10, with 10 being the worst pain you have had, how does this (pain) rate?” “What was your 10 previously?”
“How does this affect your daily activities?”
“How many episodes?”
“Is it getting worse, better, or staying the same?”
Timing
chronology, type and time of onset, intervals between occurrences, duration of symptoms, frequency
“When did it start?”
“Did it come on gradually? Or suddenly?”
“How long does it last? “
“Is it constant? Or come and go (intermittent)?” (seasonal?)
“How often does it occur?”
“Is it worse at a particular time of the day?”
Setting
environmental factors, personal activities, emotional reactions, other circumstances that may contribute
“What were you doing when it started? “
“Where were you? “
“Who else was present?”
Aggravating and/or Alleviating factors:
“Does anything make it worse?” -aggravate
“Does anything make it better?” -alleviate
Examples: cold, heat, positions, movement, rest, therapy, medications (always ask including OTC, herbals), certain foods
Associated symptoms:
other symptoms common to a condition, or nonspecific symptoms that reflect the impact of the disease
“Have you noticed any other symptoms along with this?”
You may need to provide some suggestions.
Open-ended: (General)
Elicit the patient’s description in their own words
Reflects the patient’s concerns with minimal bias from the interviewer
Closed-ended: (Specific)
Answered with a “ Yes”, “No”, or a brief response
Most useful for clarifying details
most prominent during clinician centered part of interview
At this time need to ask for yes or no questions, feel free to let me know if you have to embellish
When conducting an HPI how do you conduct the interview?
Always begin with open ended questions
Invite the patient to tell you their story and be prepared to listen for a few minutes.
Example: “You’ve told me you’ve been having chest pain. Could you tell me more about it? Please start from beginning.”
Then fill in the blanks by using your sacred seven (components of symptoms)
Pertinent Postiive and Negative
Information obtained during the interview that supports or helps rule out specific diagnoses
Pertinent negatives are factors that, if present, would have suggested a different diagnosis.
Most pertinent positives and negatives can easily fit into a well-organized HPI.
Answers to associated symptom questions often fit into this category.
A general rule is to use pertinent positives and negatives only when they are relevant to your differential diagnosis.
Parts of the Review of Systems (ROS), Past Medical History (PMH), Family history (FH), and Social History should be included in the HPI.
You will not likely know what the pertinent positives and negatives are until the end of the encounter
AIDET
A = Acknowledge I = Introduce (name and title) D = Duration (how long things will take when you think people will come) E = Explanation T = Thank You
