Intro to Patient History

Question 1

You are to ask what type of questions?

Answer 1

Begin with OPEN interview questions that allows patient to tell you a story, instead of them saying yes or no. You get more information that way.

Question 2

PEARLS: Your goal is to establish rapport

Answer 2

Partnership – you and patient work together

Empathy –acknowledge feelings - repetition

Apology – Apologize if late etc. or staff rude

Respect – value patients choices, behaviors, decisions. speak in low voice. Call by appropriate title. Wash your hands in front of them if you can.

Legitimization - show understanding of patient situation. “that could happen to anyone”

Support – Let the patient know they can contact you for more information.

Question 3

What are the 4 steps for history?

Answer 3

• open questions
• affirmations
• reflections
• summaries

Question 4

Empathy – N.U.R.S.E.

Answer 4

• Naming
• understanding
• respecting
• supporting
• exploring

Question 5

What are 3 things medical documentation provide?

Answer 5

1. Reimbursement
2. Record of what was done for any other provider to review
3. Legal document – if it is not written down then you did not do it.