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Patient Interviews . Initial interview with patient is very important Patient’s medical and health history is the basis for all treatment rendered by the practitioner Think of questions that are asked?. Patient Interview and History Introduction. Effective listening
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Initial interview with patient is very important • Patient’s medical and health history is the basis for all treatment rendered by the practitioner • Think of questions that are asked? Patient Interview and History Introduction
Effective listening • Being aware of nonverbal clues and body language • Using a broad knowledge base • Summarizing to form a general picture Interviewing Skills
1) Do your research before the patient interview • 2) Plan the interview • 3) Approach the patient and request the interview • 4) Make the patient feel at ease • 5) Deal with sensitive topics with respect • 6) Do not diagnose or give a diagnostic opinion • 7) Formulate the general picture • 8) Conduct the interview in private without interruptions Interviewing Successfully
Most charting methods are based on a series of steps to document information • SOAP Method • 1) Subjective data: obtained through conversation with patient. Thoughts, feelings, and perceptions • 2) Objective data: apparent and measurable. Vital signs and test results • 3) Assessment: the physicians diagnosis or impression of the patient’s problem • 4) Plan of action: Options for treatment Methods of Charting
(1) Personal Data – Name, Birthday, etc. • (2) Chief Complaint – Main reason patient came to office • (3) History of present Illness – medications taken, pain scale • (4) Past medical History – any and all past and present illnesses and surgeries • (5) Family History – can help lead practitioner to a diagnosis • (6) Social and occupational history – marital status, occupations • (7) Review of symptoms Health History Form
Activity Time • Procedure 5-1 p. 104 • Procedure 5-2 p. 117