health history interview social conversation vs aim for other’s health improvement express one’s...
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Health History Interview
Social Conversation
vs
Aim for other’s health improvement
Express one’s interest or need.Responsible for oneself
Health History Interview
1. Establish trust & supportive relation
2. Gather information
3. Offer information
Most value skill of clinical care
Much more than just asking a question
ObjectiveObjective
Techniques promote trust & communication
Unfold the patient’s story in detailed form
Generate hypothesis about the nature of patient’s concernGenerate hypothesis about the nature of patient’s concern
Test hypothesis by asking more detailed informationTest hypothesis by asking more detailed information
Explore the patient’s belief and feelingsExplore the patient’s belief and feelings
If little can be done, discussing the patient’s experience can be RxIf little can be done, discussing the patient’s experience can be Rx
clin
ical
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pt’s perspective
Rx
Health History Format
Structured framework for
patient’s information
Structured framework for
patient’s information
Focus clinician’s attention on
specific pieces of information
Focus clinician’s attention on
specific pieces of information
Interview Process
Generate the piece of
information is more fluid
Generate the piece of
information is more fluid
Require :
knowledge of information
ability to elicit accurate and detailed
information
interpersonal skill response pt’s
feeling
Require :
knowledge of information
ability to elicit accurate and detailed
information
interpersonal skill response pt’s
feelingusually clinician’s perspective Include patient’s perspective
Factors that influent health history
1. Patient’s need and concern
2. Clinician goal of encounter
3. Clinical setting (IPD, OPD, PCU, subspecialty)
Getting Ready: the approach to interview
Require planning:
Take time for self reflection
Reviewing the chart
Setting goal for the interview
Reviewing clinician behavior and appearance
Improving the environment
Taking note
clinician
information
patient
Take time for self reflection Take time for self reflection
Clinician’s challenge: Clinician’s challenge:
being consistency open and respectful toward
Individual differences.
is a continual part of professional development in clinical work
must look inward to clarify how our own expectation
and reaction (value, assumption, bias).
Reviewing clinician behavior and appearance Reviewing clinician behavior and appearance
Just you observe the patient, the pt. will be watching you.
Consciously or not, you sent message through words
and behavior.
Being sensitive to non-verbal message, should be calm and
unhurried, even time limited.
Must take pain, not to express negative feeling.
Try to consider the pt’s perspective, you want the pt. to trust you
Reviewing the chart Reviewing the chart
Goal Goal
gather information
develop ideas about what to explore
should not let the chart prevent you to develop new idea.
Setting goal for the interview Setting goal for the interview
Student → write up patient’s report
Clinician → make healthy balance between
provider centered goalprovider centered goal patient centered goalpatient centered goal
institute
health insurance
family
Taking note Taking note
do not let note taking distract you from pt.
jot down specific words, not in format
keep eye contact, put down the pen during sensitive feeling
when find uncomfortable, explore concern and explain,
you need accurate record
always keep eye on patient’s feeling
Improving the environment Improving the environment
sitting distance
making privacy and comfortable
Learning about the patient’s health
devote timedevote time
fully ready to listenfully ready to listen
elicit patient’s concernelicit patient’s concern
The process of interview
Greeting the patient and establish rapport
Inviting patient’s story
Establish the agenda for interview
Expand and clarify the patient’s story
Generate and testing diagnostic hypothesis (clinician perspective)
Create shared understanding of problems
Negotiating a plan
Planning to follow up and closing interview
Greeting the patient and establish rapportGreeting the patient and establish rapport
Physical setting shape the patient first impression
Greet the patient by name
Maintain confidentiality
Let the patient decide if third party needed
Attune the patient’s comfort
Arrange the seat in appropriate distance
Spend small talk to put the patient as ease
Inviting patient’s storyInviting patient’s story
Chief complaint : begin with open question
Listen without interrupt, give opportunity to response fully
Train yourself to follow the patient’s lead, listen actively,
use continuer… go on
Establish the agenda for interviewEstablish the agenda for interview
The clinician always approach with specific goal in mind,
the patient also has specific questions and concerns
Identify at the beginning, allow time effectively, make sure
you addressed all patient’s issues
If many problems…approach the most concerned one…list
others…all are important…will be addressed at next visit
Expand and clarify the patient’s storyExpand and clarify the patient’s story
Use understandable language (pt’s word)
Facilitate pt’s story by different type of questions
Move back and forth from open ended questions to direct
question to another open ended question
Established sequence and time course
Each symptom must be clarified: 7 attributesLocationCharacterSeverityTimingSettingRemitting/aggravatingAssociated symptoms
Generate and testing diagnostic hypothesis (clinician perspective)
Generate and testing diagnostic hypothesis (clinician perspective)
Specific detailed might differentiated one disease
from another
Built evidence for and against diagnostic possibility
Review systems for additional data
Create shared understanding of problemsCreate shared understanding of problems
“disease” vs. “illness”“disease” vs. “illness”
To understand the patient’s expectation & concern -
asking patient-centered questions in 6 domains:
the pt’s thought about illness
the pt’s feeling, fear
the pt’s expectation
effects to the pt’s life
prior experience
Rx response already tried
Negotiating a planNegotiating a plan
Help the patient create complete picture of problems
and form a basis for planning further evaluation.
Autonomy and voluntariness
Planning to follow up and closing interviewPlanning to follow up and closing interview
May find that ending if difficult, if pt. enjoys discussing
May close up with summary plan.. take medicine…get
blood test and make appointment for next visit.
If pt. brings new issue, simply reassure of your interest,
make plan to address this problem in future time
Facilitate the patient’s story
Active listening
Adaptive questioning
Non-verbal communication
Facilitation
Echoing
Empathic response
Validation
Reassurance
Summarization
Highlighting transition
Adaptive questioning Adaptive questioning
1. Direct questioning from general to specific
use open-ended question
2. Questioning to elicit graded response
3. Asking a series of questions at one time…
4. Offering multiple choice for answer
5. Clarifying what the patient means
Comprehensive Health History Format
Date and timing
Chief complaint (s) : pt’s words
Present illness : including bellowed relevant history
Past history: medical, surgical, Ob-Gyn, vaccination, screening for diseases
Family history: hereditary, contact diseases, cancer, cause of death,
Personal and social history: occupation/school, source of stress, economic,life style, belief, health and safety behavior – diet, exercise, comparative medicine,drugs, alcohol, smoking
Review of systems
Identifying data Reliability
Preparing the physical examination
Reflect on your approach to the patient
Decide on the scope of examination: comprehensive or focused
Choose the examination sequence: head to toe
Adjust the lighting and environment: adjust bed, tangential light
Promote patient comfortable:
Reflect on your approach to the patientReflect on your approach to the patient
Appear calm organize and competent
Avoid showing distaste, alarm, or negative reaction
Sharing the findings with patient
Make sure washing your hand in the presence of patient.
Promote patient comfortable:Promote patient comfortable:
Keep privacy, consider third party
Art of draping: visualize one area of the body at a time
Keep pt. informed when anticipate discomfort or embarrassment
Give instructions at each step
Be sensitive to the patient’s feeling, watching facial expression
When finished, tell the pt. general impression and what to expect next.
Rearrange the environment to the pt’s satisfaction