Lesson 2 Flashcards
A conversation with a purpose within three folds
Health history interview
Structured framework for organizing patient information
Health history format
Patient’s information is concisely organized into three categories
Past
Present
Family history
4 phases of interview
Pre-interview
Introduction
Working
Termination
Set the stage for a smooth interview
Pre-interview
A continual part of professional development in clinical work
Self reflection
Put the patients at ease and establish a trust
Introduction
Obtain the patient information
Working
What are the seven attributes of a symptom
Onset
Location
Duration
Characteristic symptoms
Associated manifestation
Relieving factors
Treatment
When did does it start
Onset
Where is it? Does it radiate?
Location
How long does it last?
Duration
What is it like? How severe it?
Characteristic symptom
Have you noticed anything else that accompanies it?
Associated manifestation
Is there anything that makes it better or worse?
Relieving factors
What have you done to treat this? Was it effective?
Treatment
Summarize important points ; discuss plan of care
Treatment
Information from the client’s point of view
Subjective data
What type of data is symptoms?
Subjective data
These are observable and measured data
Objective data
What type of data is signs
Objective data
A complete clear and chronologic account of the problems prompting the patient to seek care
HPI - History of Present Illness
