● Basic and Advanced Interviewing Techniques
Basic Interviewing Techniques
● Active listening: Active listening means closely attending to what the
patient is communicating, connecting to the patient's emotional state
...
● Basic and Advanced Interviewing Techniques
Basic Interviewing Techniques
● Active listening: Active listening means closely attending to what the
patient is communicating, connecting to the patient's emotional state, and
using verbal and nonverbal skills to encourage the patient to expand on
his or her feelings and concerns.
Empathic responses: Empathy has been described as the capacity to
identify with the patient and feel the patient's pain as your own, then
respond in a supportive manner.
Guided questioning: Guided questions show your sustained interest in
the patient's feelings and deepest disclosures and allows the interviewer
to facilitate full communication, in the patient's own words, without
interruption.
Nonverbal communication: Nonverbal communication includes eye
contact, facial expression, posture, head position and movement such as
shaking or nodding, interpersonal distance, and placement of the arms or
legs—crossed, neutral, or open.
Validation: Validation helps to affirm the legitimacy of the patient's
emotional experience.
Reassurance: Reassurance is an appropriate way to help the patient feel
that problems have been fully understood and are being addressed.
Partnering: When building rapport with patients, express your
commitment to an ongoing relationship.
Summarization: Giving a capsule summary of the patient's story during
the course of the interview to communicate that you have been listening
carefully.
Transitions: Inform your patient when you are changing directions during
the interview.
Empowering the patient: Empower patients to ask questions, express
their concerns, and probe your recommendations in order to encourage
them to adopt your advice, make lifestyle changes, or take medications as
prescribed.
Advanced Interview Techniques
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Determine scope of assessment: Focused vs. Comprehensive:
Comprehensive: Used patients you are seeing for the first time in the office or
hospital. Includes all the elements of the health history and complete physical
examination.
Is appropriate for new patients in the office or hospital
Provides fundamental and personalized knowledge about the patient
Strengthens the clinician–patient relationship
Helps identify or rule out physical causes related to patient concerns
Provides a baseline for future assessments
Creates a platform for health promotion through education and counseling
Develops proficiency in the essential skills of physical examination
Focused: For patients you know well returning for routine care, or those with
specific “urgent care” concerns like sore throat or knee pain. You will adjust
the scope of your history and physical examination to the situation at hand,
keeping several factors in mind: the magnitude and severity of the patient’s
prob- lems; the need for thoroughness; the clinical setting—inpatient or
outpatient, primary or subspecialty care; and the time available.
Is appropriate for established patients, especially during routine or urgent
care visits
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific body system
Applies examination methods relevant to assessing the concern or problem as
thoroughly and carefully as possible
Being aware of your reactions helps develop your clinical skills.
Your success in eliciting the history from different types of patients grows with
experience, but take into account your own stressors, such as fatigue, mood, and
overwork.
Self-care is also important in caring for others. Even if a patient is challenging,
always remember the importance of listening to the patient and clarifying his or
her concerns.
Components of the Health History
Initial information
Date and time of history-time is especially important in emergent situations
Identifying data-age, gender, marital status, occupation-identify source of history ie: family
member, friend etc.
Reliability-usually documented at end of interview ie: “patient is vague when describing
symptoms”.
Chief Complaint(s)
Try to quote the patients words
Present Illness
Complete, clear and chronological description of the problem prompting the patient visit
Onset, setting in which it occurred, manifestations and any treatments
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Should include 7 attributes of a symptom:
Location
Quality
Quantity or severity
Timing, onset, duration, frequency
Setting in which it occurs
Aggravating or relieving factors
Associated manifestations
Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives”
when doing Review of Systems that are relevant to the chief complaint.
Present illness should reveal patient’s responses to his or her symptoms and what effect this
has on their life.
Each symptom needs its own paragraph and a full description.
Medication should be documented, name, dose, route, and frequency. Home remedies, nonprescriptions drugs, vitamins, mineral or herbal supplements, oral contraceptives, or
borrowed medications.
Allergies-foods, insects, or environmental, including specific reaction
Tobacco use, including the type. If someone has quit, note for how long
Alcohol and drug use should always be investigated and is often pertinent to the Presenting
Illness.
Past history
Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever,
scarlet fever, and polio. Also include any chronic childhood illness
Adult illnesses: Provide information in each of the 4 areas:
Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitaliations; number and
gender of sexual partners; and risk taking sexual practices.
Surgical: dates, indications, and types of operations
Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and
sexual function.
Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments.
Health Maintenance: Find out if they are up to date on immunizations
and screening tests.
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Family history
Outlines or diagrams age and health, or age and cause of death, of siblings,
parents, and grandparents
Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, elevated cholesterol levels, stroke,
diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung
disease, headache, seizure disorder, mental illness, suicide, substance abuse,
and allergies, and symtoms reported by patient.
Ask about history of breast, ovarian, colon, or prostate cancer
Ask about Genetically transmitted diseases
Personal or social history
Describes educational level, occupation, family of origin, current household,
personal interests, and lifestyle
Capture the patients personality and interests, sources of support, coping
style, strengths, and concerns
Includes lifestyle habits that promote health or create risk, such as exercise
and diet, safety measures, sexual practices, and use of alcohol, drugs, and
tobacco
Expanded personal and social history personalizes your relationship with the
patient and builds a rapport
Review of systems
Documents presence or absence of common symptoms related to each of the
major body systems
Understanding and using Review of Systems questions may seem challenging at first. These “yes-no” questions should come at the end of the interview. Think about asking a series of questions going from “head to toe.” It is
helpful to prepare the patient by saying, “The next part of the history may
feel like a hundred questions, but it is important to make sure we have not
missed anything.”
Most Review of Systems questions pertain to symptoms, but on occasion,
some clinicians include diseases like pneumonia or tuberculosis.
Note that as you elicit the Present Illness, you may also draw on Review of
Systems questions related to system(s) relevant to the Chief Complaint to
establish “pertinent positives and negatives” that help clarify the diagnosis.
For example, after a full description of chest pain, you may ask, “Do you have
any history of high blood pressure . . . palpitations . . . shortness of
breath . . . swelling in your ankles or feet?” or even move to questions from
the Respiratory or Gastrointestinal Review of Systems
The Review of Systems questions may uncover problems that the patient has
overlooked, particularly in areas unrelated to the Present Illness. Significant
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health events, such as past surgery, hospitalization for a major prior illness,
or a parent’s death, require full exploration. Keep your technique flexible.
Remember that major health events discovered during the Review of Systems
should be moved to the Present Illness or Past History in your write-up. ■
Some experienced clinicians do the Review of Systems during the physical
examination, asking about the ears, for example, as they examine them. If the
patient has only a few symptoms, this combination can be efficient. If there
are multiple symptoms, however, this can disrupt the flow of both the history
and the examination, and necessary note taking becomes awkward
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Subjective versus Objective Data
Subjective versus Objective Data (pg. 7)
7
Subjective Data (symptoms) Objective Data (signs)
What the patient tells you What is observed during
physical examination
Patients history, from Chief
Complaint through Review of
Systems
Laboratory information, test
data
Documentation
Documentation needs to be CLEAR, CONCISE, COMPREHENSIVE.
SOAP (subjective, objective, assessment, & plan) note is used for providers of various
backgrounds/specialties to communicate with each other.
Ch. 2
1. Clinical Decision Making
Critical Thinking and Reasoning
Differential Diagnoses
Differential Diagnosis: A list with potential causes of patient specific problem/CC
• A chief complaint (CC) must be identified first.
• The differential diagnosis will include all medical disease that may possibly
explain problem/ CC.
• The differential diagnosis must include the most likely diagnosis and even at
times the most serious diagnoses that have serious consequences if undiagnosed and
untreated.
• The differential diagnosis list should begin with the most likely explanation
or etiology for the problem/CC.
EX: C/O vomiting blood
1. Peptic ulcer
2. Cirrhosis with bleeding esophageal varices
3. Acute hemorrhagic gastritis
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