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
patient-centered interviewing
biopsychosocial model
Allows the clinician to explore the patient’s feelings/thoughts
Encourages the patient to discuss the experience of illness (how is it affecting their everyday life?)
Patients share in the responsibility for their care (contributing to their process)
Patients want to be informed (feels respected)
Set the agenda, allow them to talk
Clarify the chief complaint, and prioritize other issues. not dismissing issue and see back to evaluate others
open=ended questions
Wh questions
Close ended questions
clinician-centered interview
medical model uses close=ended questions for brief answers
when would a clinician centered interview be more imperative
emergency situation, situation where the patient has severe psychological issues for these instances for clarity focus on biomedical issues
when using the patient centered interview style contribute to conversation by
Begin with non-focusing open ended skills. Be prepared to listen for a few minutes.
Explore the patient’s story in more depth.
Use emotion-seeking skills and emotion-handling skills.
Create a shared understanding of the patient’s concerns
Elicit the patient’s description, in their own words.
Reflects the patient’s concerns with minimal bias from the interview.
summarize at end so they know you have listened taking concern seriously and are willing to help
Examples:
“Can you tell me more about that?”
“What else did you notice?”
“Tell me what the pain was like.”
What do you do if the patient doesn’t open up?
If the patient does not talk freely, use focusing open-ended skills:
Reflection, echoing
Open-ended requests
Examples:
“Tell me more”
“Tell me what else you noticed”
Summary/Paraphrasing– the interviewer indicates his/her understanding of the story, and encourages the patient to express deeper feelings
6 Wh questions?
where on your body?
What does it feel like?
when does it start? does it come and go?
how is it affected by sleep, food, exertion, etc.?
why do you think you have this problem?
who is affected by it (consequences to themselves or others)
What questions do you avoid?
Leading questions
You haven’t had any sexually transmitted diseases, have you?
Rapid-fire questions (compound questions)
Are you having any coughing or chest pain?
Medical jargon questions
“Have you ever had an MI?”
“Any history of COPD?”
active listening
means closely attending to what patient is communicating, connecting o the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her findings or concerns.
A structured way of listening and responding to others that focuses attention on the speaker:
Observe Patient comfort
Patient tells story
Listen for the data
Listen for the patient’s interpretation
Listen to the tone and inflection of words (happy or upset)
Note discrepancies between what the patient says and how s/he says it, and discrepancies between words and gestures
Nonverbal Communication
The process of transmitting information without the use of words
Expression and movement
Personal space- Moving closer or placing a hand on a patient
Paralanguage – pauses, tone, rate of speech, pitch, volume and articulation evident in speech
Artifacts – clothing, jewelry, tattoos, piercings, uniforms
Attention to your own non-verbal behavior requires self-awareness and discipline
respect
To value an individual’s traits and beliefs despite your own personal feelings about them
To be able to see patient’s feelings and behaviors as valid adaptations to their illness or life circumstances
Requires that the provider separates personal feelings about the patient’s behavior or attitude from the goal of helping the patient get well
genuineness
The ability to be yourself both as a person and as a professional
Be clear with your patients about what you know; what you do not know; what you can and can not do (overiestimation is when people get hurt)
Be able to express feelings within the boundaries of a professional relationship
Demonstrate your interest in the patient as a person
empathy
Empathy = Objective awareness and insight into feelings, emotions and behaviors of another person.
The skill is in maximizing your ability to gather accurate data about the patient’s thoughts and feelings, and then demonstrating your understanding.
Verbal responses (don’t say well at least you don’t have this)
capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner
Nonverbal responses
(i understand while i haven’t had this i can understand what you are going through, rarely a response can make something better but it can make a connection.
summarization
Summarize what you have heard from the patient
Indicates to the patient that you have been listening
Clarify anything you may have misinterpreted
Helps you organize your clinical reasoning
Conveys your thinking to the patient, making the relationship more collaborative
empowering the patient
Ultimately, patients are responsible for their own care
Principles of Sharing Power:
Inquire about the patient’s perspective
Express interest in the person, not just the problem
Follow the patient’s leads
Elicit and validate emotional content
Share information with the patient
Make clinical reasoning transparent to the patient
Reveal the limits of your knowledge
Objectives:
1. Compare and contrast the components of a comprehensive patient history and physical with a problem-focused patient encounter in terms of format, purpose and scope.
a problem-focused patient encounter in terms of format, purpose and scope.
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
- Define the following as they apply to patient encounters:
Differential diagnosis
Review of systems
list of possible disases or conditions that could be causing your symptoms based off of the information you have
General, Skin, HEENT, Neck, Breasts, Respiratory, Cardiovascular, Gastrointestinal, Peripheral vascular, Urinary,
- Use appropriate descriptive terminology to describe history and physical examination findings.
…
- Compare and contrast patient-centered interviewing with clinician-centered interviewing.
patient-centered interviewing biopsychosocial model, Allows the clinician to explore the patient’s feelings/thoughts, Encourages the patient to discuss the experience of illness (how is it affecting their everyday life?), Patients share in the responsibility for their care (contributing to their process), Patients want to be informed (feels respected), Set the agenda, allow them to talk, Clarify the chief complaint, and prioritize other issues. not dismissing issue and see back to evaluate others, open=ended questions, Wh questions, Close ended questions
clinician centered- medical model uses close=ended questions for brief answers
- Describe the purpose of the medical interview.
information gathering, relationships building, patient education
- Compare and contrast questioning skills with relationship building skills.
..questioning skills just gives you answers to what is wrong today relationship skills shows an interest to the person as a whole asking about social history emotions
- Describe the techniques of skilled interviewing, and define the following terms as they apply to the skills of the patient interview:
Active listening “Wh” questions Confrontation Direct inquiry Echoing Emotion handling skills Emotion seeking skills Empathy Empowering the patient Facilitators
Focusing Skills Indirect inquiry Interchangeable response Naming and labeling Neutral utterances and continuers Non-focusing skills Nonverbal communication Paralanguage Paraphrasing Partnership
Personal Space Praise Reflection Relationship building skills Respect Self-disclosure Silence Summarization Support Understanding
- Discuss the therapeutic core qualities that allow good clinicians to be able to connect with their patients.
Empathetic, patient, calm, respectful, caring, attentive
- Communicate effectively with patients while building an accurate and thorough patient history.
…
10. Describe and give examples of • Chief complaint • History of present illness • Lifestyle habits • Past medical history • Family history • Health maintenance and screening tests • Personal habits and Social history • Review of systems
- Chief complaint why the patient come in. ex. ankle pain
- History of present illness what happened sequences that caused patient to come in ex. chest pain beginning when I woke up
- Lifestyle habits what the patient’s daily life, diet, and work life are like ex. high stress job heavy smoking
- Past medical history- general medical history of patient ex. stroke in 2002
- Family history- history of parents or family illness allowing you to gestimate what the patient genetically has in their history
- Health maintenance and screening tests- tests that can be done to see if there is genetic or biological predisposition to a certain disease or disorder ex. breast cancer screening
- Personal habits and Social history- romantic and family history relationships and how they impact the patients mental health day to day. social history is their group of friends and people they spend time with and how they impact the patient. ex. abusive parents and significant other cause high stress
- Review of systems- overview of the patients general systems for a full check up
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 member, friend, medical record
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.
Components of the Comprehensive Adult Health History
Identifying data, source and reliability Medications Allergies Lifestyle habits (ETOH, tobacco, recreational drugs) Past Medical History Childhood illnesses Adult illnesses Hospitalizations, surgeries, transfusions Accidents & injuries Family History Health maintenance & Screening Tests Personal habits and Social history Review of Systems (ROS)
current medications
Ask pt about prescription drugs, OTC drugs, herbals and supplements
Ex: vitamins, oral contraceptives (OCP, BCP), borrowed meds
You can ask the patient to bring in bottles, important to know what other providers are prescribing
Resources to look up meds: Epocrates, Clinical Pharmacology (through Schaffer Library
List drug name, strength, dose, form (capsule, tablet, liquid, drops, spray, inhaler), route, frequency. include what medication is being taken for if related to CC
Examples:
Lasix [drug] 20 mg [strength] one [dose] tablet [form] oral [route] twice a day [frequency].
Advil 200 mg 2 tablets po twice daily prn for pain
Allergies & Sensitivities
Ask about allergies, sensitivities and/or reactions to: (specify each)
Food
Drugs
Environmental (plants, insects, pets, etc.)
Ask each individually and not in compound question
Patients will often state they have an allergy when they have sensitivity.
Many meds have known side effects too!
Allergen and reactions - Examples: Allergies: Penicillin – “high fever” 105o Soy allergy – rash “all over” Grass pollens – itchy & watery eyes, & sneezing
Many reported allergies by patients are actually sensitivities and can be reported under allergies as sensitivities. For example:
Sensitivities:
“Codeine”- vomiting.
“Milk allergy”- indigestion (they lack lactase to digest lactose)
List sensitivities below allergies as a separate heading.
Review of Systems
General Skin HEENT Neck Breasts Respiratory Cardiovascular Gastrointestinal
Peripheral vascular Urinary Genital Musculoskeletal Neurologic Hematologic Endocrine Psychiatric
Review of Systems location in history
It is usually performed as the last part of the medical history.
It is sometimes given to a patient in written form to complete before they see you.
Although performed last, the information obtained should be incorporated into the HPI for a problem-focused visit
It is usually performed as the last part of the medical history.
It is sometimes given to a patient in written form to complete before they see you.
Although performed last, the information obtained should be incorporated into the HPI for a problem-focused visit
“I’d like to ask some general questions about your health to make sure I have not missed anything.”
Asking the Review of Systems
Ask a general question about each system followed by more specific yes/no questions as needed.
For example, “Are you having any trouble with your vision?”
If the answer is yes, “Are you having double vision? Is your distance vision worsening?”
You need enough detail to indicate if each positive response is significant or not.
For example, “Has this change in your vision been sudden or gradual? Has the vision changed in both eyes? Can you read? Can you see the television?”
You will tailor your ROS questions depending on the patient’s age, complaints, and general state of health
Use your clinical judgment
You may elicit information that belongs in the HPI.
You may elicit information that belongs in the Past Medical History.
Organize this information only after the interview and exam are completed
Figure out the best place to put info learned.
Avoid repeating info within your record.
Include symptoms relevant to the CC in the HPI.
Include what you consider major health events in the Past Medical History.
Positive Review of systems
Remind the patient to focus on currently distressing symptoms
Make questions general.
Focus on the meaning of the symptom.
Maybe you have not elicited enough information about the patient’s chief complaint.
The patient may have an underlying agenda that has not yet been addressed.
BID,
2 times a day
TID
three times a day
po
orally
prn
as needed
MDI
metered dose inhaler
od
once a day right eye
os
left eye
ou
both eyes
ac
before a meal
qhs
every bedtime
p.r.
per rectum
q
every
confrontation
hostile or argumentative meeting or situation between two opposing parties. in skilled interviewing it is important to not be confrontational if you have an angry parient let them be confrtontational listen and try to calm them down to not make the situation worse for you or your patient
Direct inquiry
asking patients direct questions about symptoms of depression or begin explorary mental status examination used in silent or quiet mentally depressed patients
echoing
simply repeating patient’s last words encouraging patient to elaborate on details and feels it helps demonstrate careful listening and subtle connection w/ patient by using same words
emotion handling skills
skills a skilled interviewer has that relate to being able to understand, empathize and comfort the patient
emotion seeking skills
cues and suggestions done by a patient looking for comfort or reassurance from their provider
facilitators
people who facilitate or allow conversation o be had medical providers should make it easy for patients to be comforted and tell them about their problems
focusing skills
skilled interviewing should mean a provider can focus on the topic at hand, not get distracted and create differential diagnosis
indirect inquiry
you would indirectly inquire if the patient came in for a visit, is sensitive about a topic etc. to try to get them to open up more about it but make it part of conversation and not a blunt request
sequencing the interview
Open-ended questions Wh questions Where do you feel the pain? Closed-ended questions What did your mother die of? Do you smoke cigarettes?
Positive review of symptoms
Remind the patient to focus on currently distressing symptoms
Make questions general.
Focus on the meaning of the symptom.
Maybe you have not elicited enough information about the patient’s chief complaint.
The patient may have an underlying agenda that has not yet been addressed.
