Interview process for patients PDF

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Summary

This have and outline of the interview process used when interviewing patients...

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Phases of the interview Process Pre-interaction: 1. Before meeting the patient 2. So you are reviewing data to know a little about the patient. 3. You collect data from the medical record 4. Examples include the previous history of medical illnesses or surgeries, current medication list, and problem list in the pre-interaction phase. Beginning: 1. First time meeting the patient 2. You introduce yourself by name and state purpose of interview 3. Ask patients how they would like to be addressed 4. Provide privacy (close doors, draw curtains etc) 5. Find out how the patient would like to be addressed 6. Include some neutral topic; simple conversation about the weather

Working: 1. Collect data by asking specific questions 2. Open-ended questions (what, how, tell me more, describe) 3. Quantifying questions (when, for how long, how many, how often, rate eg rate your pain) 4. Close ended questions ( do you, have you, have you ever) 5. AVOID WHY QUESTIONS 6. Chart the patient’s history and health problems. Closing: 1. Summarizing and stating what the two to three most important patterns or problems might be. Eg. “It seems that you are most concerned about control of your pain. Would you agree?” 2. Let the patient knows next step eg. I’ll make sure to put in your plan of care to ask about

your pain level every hour.” 3. Ask whether the patient would like to mention anything or needs anything else

Data Sources and History Component Primary data source: Individual patient

Secondary data source: Charts and information from family members

Components of a health history: you collect demographic data first and then elicit from the patient a complete description of the reason for seeking health care.

Types of Health Histories: Emergency: Purpose: Nurses collect the most important information and defer obtaining details until patients are stable. They elicit the reason for seeking care along with current health problems, medications, and allergies.

Care focuses on gathering information so that interventions can resolve the immediate problem. Assessments and interventions are concurrent

Focused: Purpose: The focused health history involves questions that relate to the current situation. An example is the patient visiting the primary care provider about a cough. In this case, the nurse asks about the length, severity, and timing of the cough and other related factors. During focused health histories, nurses do not perform a complete review of systems (discussed later).

Comprehensive: Purpose: The comprehensive health history takes place during an annual physical examination, for sports participation screenings, and during a hospital admission.

It includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.

Reason for seeking care: 1. Must be in patients own words and must be in quotes 2. Record the symptoms and not the sign

History of Present Illness 1. Beginning with open-ended questions and having the patient explain symptoms. 2. Ask questions about symptoms in six to eight categories 3. OLDCARTS (onset, location, duration, character, associated or aggravating factors, relieving factors, timing, severity) 4. PQRSTU (provocative or palliative, quality, region, severity, timing, understanding patient perception) 5. Location: where does it hurt? Show me where it hurts? 6. Onset/Duration/Timing: “When did you first notice the pain?” “How long did it last?” Record the date and time specifically (month and year) 7. Intensity: “How bad does it hurt?” rate on pain scale 0-10 8. Quality/Description: “What does the pain/discomfort feel like?” “Is it sharp or dull?” or “Is it stabbing or more achy?” “Do you notice anything else when you have the pain? 9. Aggravating/Associated/Alleviating Factors: “Is there anything that you notice that makes it worse?”, “Is there anything that you notice that consistently causes or happens with the pain?” “What seems to make it better?” or “What have you tried to make it go away?” 10. Pain Goal: Ask the patient, “What is an acceptable level of pain?” or “What do you hope that we can get your pain down to?”...