Lecture 1 Flashcards
Goals for health history
Collect info on patients and illness establish contract of care w/pt Understand pt. environment Establish list of problems needing to be solved Develop problem-solving plan
Different Types of Histories
Complete (comprehensive, new patient)
Inventory (not as detailed)
Interim (events between visits)
Problem Oriented (focused on specific body system, for established patients)
Clinical note headings for “S” part of SOAP (SUBJECTVE)
ID Data and Source of history Chief Complaints History of present illness Medications Allergies past medical/surgical/family/personal/social history general review of systems
Types of Questions
Open ended
- best when seeking general info - use as beginner
Direct/closed
- Seeking specific facts; avoid as beginner
Graded Response
- graded vs. single answer
Leading
- limits info; bad
Multiple
- beginners tend to do this
Interview Techniques
Facilitation
Verbal/nonverbal
Encourages pt. to say more
Reflection
Repeat what said
Clarification, Reassurance, empathy, Confrontation (???), Interpretatiton (restate and confirm), Validation, Summarization
Ask me 3
Help patients to understand:
- What is my main problem? - What do I need to do? - Why is it important for me to do this?
4 C’s Tool
Call - What do you call your problem?
Cause - What do you think is causing your problem?
Concern - What concerns you the most that we need to address?
Cope - what are you currently doing to cope with your problem?
CAGE
More than 6 beers a night
CONCERN - your own or someone else’s? urge to cut down?
ANNOYED - criticism of your drinking?
GUILTY - about your drinking?
EYE OPENER
TACE
TAKE to get buzzed?
ANNOYED with criticism?
CUT feel urge to cut down?
EYE OPENER
> 6 beers a day, ask TACE
HITS
Domestic Violence
someone HURT you physically?
INSULT or talk down to you?
THREATEN physical harm?
SCREAM at you?
CRAFT
Underage drinking
been in CAR driven by someone under influence? use to RELAX? ever use ALONE? FORGET what you're doing while using? gotten into TROUBLE?
