Patient Assessment Key Concepts

Patient Assessment Key Concepts

• Chief Complaint: Main reason for patient's visit, e.g., sore throat.
• Final Diagnosis: Conclusion reached after evaluating findings, tests, and results.
• Differential Diagnosis: Listing of conditions that might explain a patient's symptoms (e.g., "IBS vs. Gastroenteritis").

Cognitive and Rapport

• Cognitive: Refers to operations of the mind like perception, thought, and memory.
• Rapport: The harmonious relationship between the patient and healthcare provider.

Patient Interaction Environment

• Ensure privacy: Room should be clear for the duration of the interview.
• Prevent interruptions: Minimize distractions to maintain conversation flow.
• Comfortable surroundings: Conduct interviews with patient and provider at eye level to ease anxiety.
• Judicious note-taking: Focus primarily on the patient, minimizing distractions from note-taking.

Active Listening Skills

• Restatement: Paraphrasing patient’s words to confirm understanding (e.g., "You are saying...").
• Reflection: Summarizing main ideas while acknowledging patient's feelings, demonstrating empathetic listening.
• Clarification: Simplifying or summarizing thoughts and feelings to resolve confusion.

Components of Medical History

• Database: Demographics and initial findings.
• Chief complaint (CC): Reason for visit.
• Past Medical History (PH): Summary of previous health issues and treatments.
• Family History (FH): Health details of immediate family members.
• Social History (SH): Lifestyle factors including diet, hobbies, and substance use.
• Systems Review (SR): Comprehensive examination of body systems, progressing from head to toe.

Stages of Patient Interview

• Initiation: Introduction, verification of identity, and clarification of purpose.
• Body: Exploration of patient's healthcare needs and concerns using therapeutic communication.
• Closing: Summary of the visit, confirmation of expectations, and encouraging patient input.

Therapeutic Nonverbal Behaviors

• Leaning in: Shows interest in patient’s health history.
• Facing the patient: Maintains comfort and sensitivity.
• Eye contact: Essential for effective therapeutic communication.
• Open posture: Avoids crossing arms/legs to demonstrate engagement.

Question Types

• Open-ended Questions: Encourage detailed patient responses (e.g., "How have you been feeling?").
• Closed-ended Questions: Elicit specific responses (e.g., "Do you have a headache?").