Workshop #1- Interviewing/Health History Flashcards
closely attending to what the pt is communicating, connecting to the pt’s ustate and using verbal and nonverbal skills to encourage the pt to expand on the feelings or concerns
Active Listening
You have to be able to covey that you are feeling what the pt is feeling. You need to be able to listen and see what and or how this is bothering the pt. A loss of a parent: can be terribly sad for some and a burden lifted for others
Empathetic Response
Move from _________ to more ________ questions
open ended; focused
Ask questions that require a _______ response as in “how many steps can you walk before becoming SOB?”
graded
Notice this and bring it to a conscious level. Watch for facial expression closed or open body language, posture, head position. Remember some cultures that they may be bound by
Nonverbal Communication
Confirm that what they are saying is legitimate. If in a car accident and unhurt validate that it must have been scary.
Validation
First identify and acknowledge the patients feelings; you seem upset today? If you tell them right off everything is going to be okay you have not heard the complete story yet and do not know what the out come is. Wait till the end and after testing and exam is done let them know what you think is going on. They tend to like to be heard and by doing this they feel that you are giving the care they need.
Reassurance
When building rapport express commitment to an ongoing relationship and that no matter what you will continue to provide care.
Partnering
telling the patients story back to them it shows them you have been listening and gives them a chance to correct things you may not have correct. It allows you to organize your clinical thinking and convey your thinking back to the patient.
Summarization
Tell the patient when you are changing to another area in the interview so they feel like they know what is going on. This helps them prepare for what is coming next. Now I’d like to ask f=some questions about… or before we move n to reviewing your medications is there anything else about your past health problems?
Transitioning
The patient can feel venerable. By making them feel they can ask questions, express their concerns and inquire about your recommendations, they can feel they empowered in their care and are more apt to adopt your advice, change their lifestyle, and take medication you prescribe.
Empowerment
data that the patient tells you
Subjective
data that you obtain through observation, assessment, labs, diagnostic tests, etc.
Objective
Purpose of ________ Visit:
To establish care
Needs a complete physical for work or school
Wants a “complete check up)
Comprehensive
30-60 scheduled visit
Comprehensive
15-20 minute walk-in or same-day visit
Episodic
History in the ____________ Exam:
Gather as much information about the patient such as:
Health and wellness
Illness and disease
All aspects of life that affect any of the above
Comprehensive
Physical Exam in the ____________ Exam:
Head to toe
Every system examined
Comprehensive
Physical Exam in the ____________ Exam:
May include all chronic health problems, newly established health problems
Comprehensive
Planning in the ____________ Exam:
More extensive
May have more health maintenance and preventive aspects to it
Comprehensive
Purpose in the \_\_\_\_\_\_\_\_\_\_\_\_ Exam: Acutely ill Has a specific complaint Requires a specific follow up from a previous visit Requires a medication refill
Episodic
History in the ____________ Exam:
To gather as much information as quickly as possible.
One specific issue
Anything that affects that one specific issue
Episodic
Physical Exam in the ____________ Exam:
Only the systems that are required for THIS specific complaint
Episodic
Assessment in the ____________ Exam:
Typically includes a diagnosis(ES) ONLY for the problem dealt with today
Episodic
Planning in the ____________ Exam:
Targeted. Plan addresses what is going on with the patient today.
Episodic
Documentation for \_\_\_\_\_\_\_\_\_: CC (Chief Complaint) HPI (History of Present Illness) Active Medical History Past Medical History (PMH) Childhood, Adult, Surgical, ER/Accidents/Injuries Women’s Health, Psychiatric Health Screenings/Health Maintenance Medications Allergies Immunizations Family History-3 generations Social History Tobacco, alcohol, illicit drugs, home, school, work, family situation, interests, hobbies, domestic violence screening, pain, safety, diet/nutrition, exercise/ADLs, spirituality, sexuality ROS (Review of Systems) Review ALL systems with patient
Comprehensive Visit
Documentation for \_\_\_\_\_\_\_\_\_\_\_\_: **CC **HPI **Active Medical History Past Medical History (Childhood, Adult, Surgical, ER/Accidents/Injuries, Psychiatric, Health Maintenance) **Women’s Health **Medications **Allergies **Immunizations Family –only if pertinent Social- Hx as pertinent ROS (Review of Systems) **Systems reviewed with patient are targeted
Episodic Visit
Past Medical History in the ___________ visit includes Childhood, Adult, Surgical, ER/Accidents/Injuries, Psychiatric, and Health Maintenance but you only ask about what is pertitent to the chief complaint
Episodic
In the __________ visit, only ask about family history if it’s pertinent to the chief complaint
Episodic
the way notes are always written by all medical staff so there is no confusion from provider to provider.
It provides a cognitive framework to guide healthcare workers in their clinical reasoning to assess, diagnosis, and treat a patient
SOAP Framework
SOAP=
Subjective
Objective
Assessment
Plan
___________ and ____________ data should not bleed into each other
Subjective and Objective
The reason they are here today “in quotes”
Chief Complaint
The story they have about their chief complaint
History of Present Illness
Medical Problems for which they are currently being treated, diagnosed when, does what for it?
Active Medical History
Any medical problems from the past which they are not currently being treated for. (Date, complications and/or sequelae)
There are many subcategories here which are listed .
In a complete health history cover them own.
In an episodic pick and choose
Past Medical History
there should ALWAYS be a subcategory of _____________ for any woman of childbearing age under Past Medical History. The information which MUST be covered here is Last Menstrual Period and form of contraception.
Womens Health
Name of medication, dose, frequency
Medications
Always ask specifically about medication, food, animals, environmental and latex. Indicate the reaction.
Allergies
Outline or diagram of age, cause of death across 3 generations for a complete history
For the episodic visit stay targeted
Family History
Education, Family, Household, Personal interests, Lifestyle, Employment
Personal/Social History
The garbage can of the entire history
Always comes at the very end of the ENTIRE history
Last chance to ask any questions/document answers not completely covered in the rest of the history
Last chance to ask questions/document patient answers you may have forgotten to ask
The framework for asking and documenting is still structured
Use Systems format – Head to Toe
Questions are more directive – get “yes” and “no” responses.
Will get a lot of “nos”
A negative response to certain questions about symptoms is just as important as a positive response in assessment. This is called a “significant negative”
Review of Systems
The Review of Systems is _________ only, NOT the physical exam.
subjective/history
This is the (Symptom Analysis)
The PRINCIPAL symptom should be characterized using OLDCARTS
Get “pertinent positives” and “pertinent negatives”
If the patient has more than one PRINCIPAL symptom, then make a separate paragraph for each principal symptom
What you put in the HPI is not dependent on where the patient told you something in the interview.
Follow the patient’s lead…BUT…YOU keep it organized in the interview and on paper.
History of Present Illness
O L D C A R T S \+1
Onset Location Duration Characterization Alleviating/Aggravating Factors Radiation Timing Severity Patient's Thoughts
Characterization of the symptom means…
how the patient describes the symptom
Timing of the symptom means….
improvement/worsening of the symptom of the during certain times of day
Always documenting how the patient states their words, not in your words.
Documenting it in quotes “ I can’t stop coughing at night”.
Documenting what you see and make sure to use all systems that are needed for the visit.
Documenting in the SOAP format so all providers can read without confusion
Accuracy and Precision
SOAP framework ensures _______ and _________
Accuracy and Precision
Type of screening tools that are those that the provider asks the patient while completing the history
may indicate the need for further investigation of a particular issue.
EX: alcohol screening and domestic violence screening.
commit to memory
Informal
Type of screening tools that are paper/pen format, and usually require “scoring” - or quantifying in some manner.
May require special training, education, preparation
Formal
_________ questions - alcohol
Use if you feel there has been hedging or vagueness on initial response
CAGE/TWEAK
_______ questions- check your state statutes regarding mandatory reporting of suspected domestic violence
SAFE
_____% of trafficked women inthe U.S. saw a health care provider or professional during the time they were still being held captive.Family Violence Prevention Fund (2010)
28
Examples of \_\_\_\_\_\_\_\_\_\_: Depression Screening: PHQ-2 Beck Inventory Zung Questionnaire MMSE (mini-mental status exam)
Formal Screening Tools
Evaluate \_\_\_\_\_\_\_\_\_ for: Reliability Validity Specificity Sensitivity
Screening Tools
LR of 3 increases probability by ___%
20
LR of 0.3 decreases probability by ____%
25
Which factors are major components of a client’s general background history
Socioeconomic Status and Allergies
The Review of Systems is _______ data
subjective
Likelihood Ratios convey to the provider:
diagnostic weight of the sign or symptom
Level of evidence scales are rating scales that provide the clinician with the _________ of evidence
STRENGTH
When subjective data argues against or refutes your hypothesis, this is known as a:
confounder
To measure the reliability of judgments of multiple observers, you would use a statistical measure of:
interrater reliability
