Chapter 2 Gathering Information PDF

Gathering Information Chapter 2 Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Learning Objectives 1. Define the patient interview and explain its purpose. 2. List practices to prepare for a successful patient interview. 3. Contrast subjective a...

Gathering Information Chapter 2 Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Learning Objectives 1. Define the patient interview and explain its purpose. 2. List practices to prepare for a successful patient interview. 3. Contrast subjective and objective information. 4. Differentiate between open-ended questions and closed-ended questions and give examples of both. 5. Discuss the tools used to gather patient information. 6. Discuss active listening. 7. List the types of responses that support effective communication. 8. Discuss the importance of summarizing patient information. Copyright © 2020 by Elsevier, Inc. All Rights Reserved  The Patient Interview Conversation between HCP and pt to obtain relevant info Covers pt’s Chief complaint Medical history Medications Family history Review of systems (ROS) Line of inquiry can change based on overall medical condition and chief complaint Patient information is confidential, private, and may only be shared with the patient’s consent Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Setting the Stage Setting should be comfortable as well as private Greet properly Surname and title Introduce yourself Handshake if appropriate Sit at pt’s eye level Use open body language Smiling and nodding builds trust Practice good personal hygiene and grooming Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Gathering Patient Information Subjective – experienced by the individual symptoms and current complaint chief complaint (C.C.) – pt’s most significant or serious reason for concern Onset of problem Location of the complaint Duration of the problem Pain Measured on pain scale Quality of pain – sharp, dull, throbbing Objective – observed and measurable no room for interpretation Ex: Bloodwork, labs, heart rate, BP Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Getting to the Point Open-ended questions – a question for which the responder must give a longer, freeform answer Asks “what” or “how” to provoke detailed answers Cannot be answered with a simple “yes” or “no” Avoid asking “Why?” as it can imply wrongdoing by pt Closed-ended questions – a question with a limited set of possible answers Elicit short answers – “How many pills do you take?” Often used to clarify, or to reassure Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Obtaining a History How may we help you?” “Can you describe the....(pain, sensation, bleeding, etc.)?” “How long has this been bothering you (or going on, etc.)?” “What happened to cause you to ask for help? Did it get worse, bother you more, etc?” “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?” or “What are you taking?” “How much....?” “How many....?” “How often....?” Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Leading the Way HCP must sometimes skillfully refocus the conversation Lead the conversation, but avoid asking a leading question Encourages or expects a certain answer “You never had unprotected sex, did you?” Cuing – inadvertently eliciting an answer by giving positive or negative feedback that signals what the questioner expects or wants to hear “How is your hand today?” “I think it is worse than ever.” “Are you sure?” Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Information-Gathering Tools (1 of 2) Algorithms – A step-by-step procedure for solving a problem using a logical progression A series or path of questions to follow that changes based on the pt’s response at each step May be too focused or too general in certain situations Acronym – A simple phrase or word formed by the initial letters of a series of words Even the best acronym will not replace your responsibility to adapt and adjust your questions Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Information-Gathering Tools (2 of 2) Example of a popular healthcare acronym for general visit: Medications – What medicines do you take, how much Diet – Daily diet, recent weight gain or loss Visits – Any recent trips to ER since last visit? Injuries – Any recent injuries, slips, falls? Symptoms – Any new symptoms, problems? Information – Any questions about medical treatment? Treatments – Following provider prescribed treatment? Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Listening to What you Hear (1 of 2) Active listening – the full attention of the listener to comprehend, respond to, and remember what the speaker is communicating Requires recognizing verbal, nonverbal cues and focused perception Gating - to consciously block reception of sensory stimuli, such as hearing or pain Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Listening to What you Hear (2 of 2) Focus on spoken word, paralanguage, body language Look for cues that conflict with pt’s words, incongruence Active listening is developed over time, can be improved Sometimes a pt’s C.C. isn’t the main issue and active listening will help discover the greatest concern Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Reflective or Paraphrasing Responses Reflective responses – a statement confirming that you received the message but leaving room for the pt to complete their thought or explore it further “Mr. Smith, you were saying that you began to have this problem when you…” and allow pt to supply missing information Paraphrasing – To restate in other words that originally transmitted, usually to make the meaning clear Pt may say “Nothing has any taste.” Your paraphrase may be “You are saying that your food does not taste Copyright as by © 2020 you feelInc.itAllshould?” Elsevier, Rights Reserved  Clarifying Clarify – removing any confusion by making clear what patients say to us and what we say to them Do not presume a pt knows medical terms or procedures Abbreviations can be very confusing Ask pt to use examples “It feels like an elephant is sitting on my chest” Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Productive Silences Some people are uncomfortable with silence and will try to fill quiet moments with words Well-timed silences allow patient to: Form new thoughts Organize ideas Remember events Silence can allow for more focused observation Encourage silence if pt seems scattered or confused Copyright © 2020 by Elsevier, Inc. All Rights Reserved  Summarizing the Information Summarizing – restating information in a briefer form Highlights main points given by pt Allows pt to clarify any concerns after you summarize them Shows you understand Ensures you have covered all concerns Copyright © 2020 by Elsevier, Inc. All Rights Reserved