Patient Interviewing: Key Concepts

Patient Interviewing: Key Concepts

• Goal: Gather subjective and objective patient data to assess needs and develop a care plan. This applies across various healthcare settings.

Subjective vs. Objective Information

• Subjective: Information from the patient, potentially inaccurate, reflecting their perception (e.g., medication side effects, adherence).

• Objective: Information verifiable without the patient, from records or other providers (e.g., past medical history, lab results, vital signs).

Three Steps to a Patient Interview

1. Setting the Stage

• Introduce yourself (name and title).
• Explain the purpose, benefits, and duration of the interview.
• Verify patient identity using two pieces of information (e.g., name, date of birth) to maintain HIPAA compliance.

2. Collecting Background Information

• Chief Complaint (CC): The main reason for seeking care.
• History of Present Illness (HPI): Context and background of the CC.
• Past Medical History (PMH): Previously diagnosed medical conditions.
• Social History: Lifestyle factors like: tobacco use, alcohol use, diet, exercise, occupation, and socioeconomic status.
• Family History (FH): Medical conditions of first-degree relatives.
• Physical Assessment: Information from records or direct assessment (vital signs, physical exam results).
• Medication History: Comprehensive review of current and past medications, including specifics like:
  • Medication name
  • Indication (purpose)
  • Dose, frequency, timing
  • Duration of use
  • Prescriber (if unknown)
• Evaluate: adherence, adverse events/side effects, and medication allergies (specific reaction).

3. Closing Out

• Recap and verify information with the patient ("teach-back").
• Answer patient questions using open-ended questions.
• Assess understanding (teach-back if counseling provided).
• Set up follow-up (appointments, information sharing, record documentation).

Documenting Findings

• Use interview forms tailored to the setting.
• Forms include demographic information, chief complaint/HPI, PMH/FH, social history, medication history, physical assessment, allergies/adverse reactions, and patient health beliefs/goals.

Communication Strategies

• Transitional phrases: Guide the conversation and prepare the patient.
• Open-ended questions: Encourage detailed responses, starting with "who," "what," "where," "how," or "tell me."
• Closed-ended questions: Use strategically for specific data collection.
• Empathy: Acknowledge patient emotions, listening and validating their feelings with reflective language.