Gathering Information - Chapter 2

Gathering Information - Chapter 2

• Learning Objectives:
  • Define the patient interview and explain its purpose.
  • List practices to prepare for a successful patient interview.
  • Contrast subjective and objective information.
  • Differentiate between open-ended and closed-ended questions and provide examples of each.
  • Discuss the tools used to gather patient information.
  • Discuss active listening.
  • List the types of responses that support effective communication.
  • Discuss the importance of summarizing patient information.

The Patient Interview

• Conversation between healthcare professional (HCP) and patient (pt) to gather relevant information.
• Covers:
  • Patient's chief complaint.
  • Patient's medical history.
  • Medications.
  • Family history.
  • Review of systems (ROS).
• Line of questioning may change based on medical condition and chief complaint.
• Patient information is confidential and private and can only be shared with the patient's consent.

Setting the Stage

• Create a comfortable and private environment.
• Greet the patient properly.
• Introduce yourself with your name and title.
• Offer a handshake if appropriate.
• Sit at the patient's eye level.
• Use open body language (e.g., smiling, nodding)
• Maintain good personal hygiene.

Gathering Patient Information

• Subjective: Information experienced by the individual, including:
  • Symptoms and current complaints.
  • Chief complaint (C.C.): Most significant or serious reason for concern.
  • Onset of problem.
  • Location of complaint.
  • Duration of problem.
  • Pain (measured on pain scale)
  • Quality of pain (e.g., sharp, dull, throbbing).
• Objective: Observable and measurable information, such as:
  • Bloodwork.
  • Lab results.
  • Heart rate.
  • Blood pressure (BP).

Getting to the Point

• Open-ended questions: Allow for detailed responses.
  • Start with "what" or "how" to elicit detailed answers.
  • Cannot be answered simply with "yes" or "no."
  • Avoid using "why" (it can imply blame).
• Closed-ended questions: Limit the patient's response.
  • Elicit short answers (e.g., "How many pills do you take?").
  • Used for clarification or reassurance.

Obtaining a History

• How may we help you?
• Describe the... (pain, sensation, bleeding, etc.)?
• How long has this been bothering you?
• What happened to cause you to ask for help?
• Has it happened in the past? What did you do about it that time?
• Does anything make it better or worse?
• Have you taken anything?

Leading the Way

• Healthcare professionals (HCPs) may need to subtly refocus the conversation.
• Avoid leading questions.
• Leading questions: Encourage or expect a specific response (e.g., "You never had unprotected sex, did you?").
• Cuing: Inadvertently eliciting a desired response (positive or negative feedback to encourage a certain answer).
• Example: "How is your hand today?"

Information-Gathering Tools

• Algorithms: Step-by-step procedures for problem-solving. Use a logical progression. Question path can change based on patient's responses at each step. May be too focused or general in certain situations.
• Acronyms: Simple phrases composed of initial letters of words. May not replace the importance of adjusting questions to patient situations.
• Example Acronym (general visit):
  • Medications: What medicines do you take, how much.
  • Diet: Daily diet, recent weight gain or loss.
  • Visits: Any recent ER visits, or similar.
  • Injuries: Recent injuries.
  • Symptoms: Any new symptoms.
  • Information: Questions about treatment.
  • Treatments: Treatment history

Listening to What You Hear

• Active Listening: Focused attention to comprehend, respond, and remember what the speaker says.
  • Recognize verbal and nonverbal cues.
  • Consciously block out distractions. (Gating).
• Active listening: Takes time and effort to improve.
• Cues: Spoken words, paralanguage, and body language are all important to consider.
• Incongruence: Discrepancies between verbal and nonverbal cues.
• Pt's chief complaint (C.C.): Not always the primary issue.

Reflective or Paraphrasing Responses

• Reflective responses: Confirming understanding without directly repeating.
• Paraphrasing: Restating in different words to clarify.
• Example: Pt says "Nothing has any taste"
  • Paraphrase: "You are saying your food does not taste how you feel it should?"

Clarifying

• Clarifying: Removing confusion by ensuring clear communication of patient's statements and health professional's messages/actions.
• Abbreviations/Medical terms can be confusing.
• Ask the patient to use examples.

Productive Silences

• Sometimes, silence is helpful.
• Allow time for the patient to:
  • Form new thoughts.
  • Organize ideas.
  • Remember events.
  • Silence can improve observation.

Summarizing the Information

• Summarizing: Restating information briefly.
• Highlights main points.
• Allows patients to clarify concerns.
• Shows understanding.
• Ensures concerns are covered.

Explore the essential components of the patient interview in this quiz from Chapter 2. Understand the significance of subjective vs. objective information, types of questions, and effective communication strategies needed for successful patient interactions. Test your knowledge on tools for gathering patient data.