the health history and interviewing process 2

7/30/2019 The Health History and Interviewing Process 2

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The Health History and

Interviewing Process

Laura Robbins-Frank MSN, RNC, APN


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Building a History

A good history through effective

interviewing is the key to understanding

and lays the foundation for good care.


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Importance of the History

and Physical Examination

Diagnosis is made from

History--- >70%

Physical---


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Building a History

Building a history versus taking a history

What is required to build a history and

relationship with a patient?


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Effective Communication

Nonverbal behavior

rapport

eye contact

movements body position, space

touch

physiologic parameters (breathing,

flushing, sweating)


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Enhancing Patient Reponses

Use:

open-ended questions

Avoid/limit: close-ended questions

leading questions

multiple questions


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Facilitation

Non-questioning comments/remarks

I see, Go on, Tell me more,

Ummm Reflection

Body language

Nods, eye contact, leaning forward

Silence


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Refocusing

Use if patient is rambling, scattered,

covering many problems at one time

Summarizing Allows you to check your understanding

of the history for accuracy

Clarifies the patients perspective


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Common Traps in Interviewing

Failure to get the overall picture first Premature focusing on details

Accepting vague or ambiguous answers

Providing false reassurance

Giving advice


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Common Traps in Interviewing

Using authority

Using professional jargon

Using leading or biased questions

Interrupting or talking to much Using why questions


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Components of the Complete

Health History

Identifying Information/Patient

Profile

Chief Complaint (CC)

History of Present Illness (HPI)

Past Medical History (PMH)

Family History (FH)

Personal and Social History (SH) Review of Systems (ROS)

**All of the health history is


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Identifying Information/

Patient Profile

Name

Date

Time

Age Gender

Race

Occupation

Source and reliability of source


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Chief Complaint

The major reason for the encounter as

expressed by the patient; includes duration

A direct quote is preferable

Not a diagnosis


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History of Present Illness

A clear chronological narrative account of the problem(s) for which thepatient is seeking care.

Classify symptoms into 8 dimensions:

L: Location- point to spot, radiation?

O: Onset- setting in which symptom occurred, where?

C: Characteristics- dull, sharp, burning, crampy, etc

S: Severity- graded on a 1 to 10 scale

T: Timing- duration, frequency, pattern?

A: Aggravating and Alleviating factors- what makes it better?what makes it worse?

A: Associated symptoms- includes significant negatives

M: Meaning to patient


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Past Medical History

General health-

as the patient

perceives it

Childhood

illnesses Adult illnesses

Psychiatric

illnesses Immunizations

Surgery

Serious injuries(and resulting

disability)

Medications

Allergies (andreactions)

Transfusions

Recentscreening tests

Obstetric/Gynec

ologic history


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Family History

At least a three generation analysis for

significant diseases that tend to have a

familial or genetic base.

Record age and health or age and

cause of death

Ask about heart disease, high blood

pressure, cancer, stroke, sickle cell

disease, diabetes

Others listed on page 18 in textbook


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Personal and Social History

An outline or

narrativedescription

capturing the most

important things

about the patient

as a person Habits- tobacco,

caffeine, ETOH,

drugs

Diet

Sleep

Exercise

Self

Care/Safety

Measures

Sexual History

Home

Conditions

Occupation

Environmental

Hazards

Military Record

Religious and

Cultural

Preferences

Access to Care


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Review of Systems

A specific review of each body system to

identify the presence or absence of health

related issues

Ask about common symptoms in each

system

Record negative and positive findings


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Concluding the Interview

Summarize the patients chief complaint or

problem

Ask:

Is there anything else that you wantme to know?

Is there anything else that we should

discuss today?


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Types of Health Histories

Complete Most comprehensive

Usually done the first time you see a patient

Focused History

Done for an acute problem

Only components of the history and physical examination

that relate to the chief complaint are done

Interim History

Chronicles events since last visit

Usually a follow-up visit


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Subjective vs Objective Data

Remember!

The health history is subjective

information- it is information the patient

is telling you.

The physical examination is objective

information- it is information you

observe on the patient.


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Mr. Garcia


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Your Mission

Obtain a complete health history on a

client outside of class (must be at least 50

years old)

Use format in this lecture and on BB

History must be typed, 11-12 pt font

Do not put clients name- use initials!

More Information will be forthcoming- this

will not be due until much later in the

semester

the health history and interviewing process 2

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