The Patient Interview Ch.1 Flashcards
A complete pt assessment starts and ends w/ the
patient interview
What is the purpose of the pt history?
To gather pertinent historical subjective and objective data
Most history forms contain
-Biographic data ( age, gender, occupation)
-Chief complaint
-Current meds
-Past health
- The pt’s family history
-Review of each body system
-Functional assessment
The interview allows the collection of
subjective data about pt’s feelings regarding his/her condition
During a successful interview, the practitioner performs the following tasks
- Gathers complete and accurate data
- Establishes rapport and trust
- Develop and shows interest and understanding about the pt’s health state
The art of viewing the world from the pt’s point of view while remaining separate from it
Empathy
The values, beliefs, and practices shared by the majority in a group of people
Culture
Culture includes
language, religious or spiritual practices, foods, social habits, music, and art
A formalized system of belief and worship (e.g Catholicism, Protestantism)
Religion
Entails the spirit or soul and is an element of religion
Spirituality
The knowledge of the pt’s history and ancestry and an understanding of the pt’s beliefs, artistic expressions, diets, celebrations and rituals
Culture awareness
Refraining from using offensive language, respecting accepted and expected ways to communicate, and not speaking disrespectfully of a person’s cultural beliefs
Culture sensitivity
Knowing the health care practitioners own values, attitudes beliefs, and prejudices while, at the same time keeping an open mind and trying to view the world through the perspective of culturally diverse groups of people
Culture competence
The pt’s capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment
Health literacy
Health literacy includes the pt’s ability to
read, listen, analyze, and make decisions regarding their specific health situation
Verbal techniques of communications may include
skillful use of open- ended questions or closed or direct questions and responses
An _____ ______ _________ asks the pt to provide narrative information
open-ended question
Open ended questions are used for
-used for narrative
-call for long answers
- elicit feelings, options ideas
- build and enhance rapport
Example of open ended questions
“What brings you to the hospital”
“Tell me why you have come to the hospital”
A ________ or _________ question asks the pt for SPECIFIC information
closed or direct
closed or direct question elects
short one-word or two word answer, a yes or no or forced choice
Example of a closed or direct question
“have you ever had this chest pain before?”
Closed or direct questions are used for
-specific information
- call for short one or two word answers
-elicit “cold facts”
- limit rapport and leave interaction neutral
_____________ encourages pts to say more to continue w/ the story
Facilitation
Examples of facilitating
“Mm hmm”
“ Go on”
“Continue”
“uh huh”
Used for pt’s choice of words is ambiguous or confusing
Clarification
Example of clarification
” Tell me what you mean by bad air?”
The examiner notes a certain action, feeling or statement made by the pt and focuses the pt’s attention on it
confrontation
Links events and data, makes associations and implies causes
Interpretation
Provides the pt w/ factual and objective information
Explanation
The final overview of the examiner’s understanding of the pt’s statements
Summary
During the pt interview the practitioner states: “You are worried about your child” This type of statement is an example of
Reflection
Which of the following is a closed or direct question?
“Have you had this pain before”
What is considered a negative nonverbal message of the interview
Sitting behind a desk
Which of the following is/are likely to be found on a complete pt history form
- pt’s family history
- activities of daily living
- pt’s cc
- review of each body system
What is considered a “facilitation” response?
” Mm hmmm, go on”
__________ communicates that the pt has time to think and organize what they wish to say w/o interruption by the examiner
Silence
Is used to echo (repeat) the pt’s words
Reflection
