Interviewing & Documentation

Interviewing & Documentation The Nursing interview J. Carley MSN,MA, RN, CNE Fall, 2009

Interviewing & Documentation Unit Objectives 1. Describe the five steps of the nursing process and how it applies to health assessment. 2. Describe an environment suitable for conducting an interview and physical assessment. 3. Recognize personal perceptions and behaviors that facilitate or hinder the interviewing process 4. Define effective interviewing techniques 5. Identify the components of the complete health history. 6. Describe how to assess the characteristics of a chief complaint

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place • Introduction and explanation

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place • Introduction and explanation • Purpose

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place • Introduction and explanation • Purpose • Length

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place • Introduction and explanation • Purpose • Length • Expectations

The Interview The Interview • Subjective data • Results of a successful interview • The interview as a contract between patient and examiner • Time and place • Introduction and explanation • Purpose • Length • Expectations • Confidentiality

Process of Communication The Interview • Sending

Process of Communication The Interview • Sending • Receiving

Process of Communication The Interview • Sending • Receiving • Internal factors • Liking others • Empathy • Ability to listen

The Interview Process of Communication • External factors • Ensure privacy • Refuse interruptions • Physical environment • Dress • Note-taking • Tape and video recording Slide 4-2

Establish Rapport • Get organized • Do not rely on memory • Plan enough time • Ensure privacy • Get focused • Be calm, confident, warm, and helpful

Begin the Interview • Give your name and position • Verify the client’s name • Briefly explain your purpose

Techniques of Communication The Interview • Introducing the interview • Working phase • Open-ended questions • Closed or direct questions

Techniques of Communication The Interview • Introducing the interview • Working phase • Open-ended questions • Closed or direct questions • Responses—assisting the narrative • Facilitation • Silence • Reflection • Empathy • Clarification • Confrontation • Interpretation • Explanation • Summary

How to listen • Be an empathetic listener • Use short supplementary phrases • Listen for feelings as well as words • Let the person know when you see body language that conflicts with what they say • Be patient if the patient has a memory block • Avoid the impulse to interrupt • Allow for pauses

How to ask Questions? • Ask about the main problem first = chief complaint • Focus your questions to gain specific information about the signs and symptoms • Don’t lead the witness • Restate the other person’s words to clarify • Use open-ended questions • Avoid closed –ended questions , yes or no questions

Observations • Carefully assess areas connected to verbal cues • Use your senses • Note general appearance • Observe body language • Notice interaction patterns

Techniques of Communication The Interview Ten Traps of Interviewing 1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using “why” questions

Techniques of Communication The Interview • Nonverbal skills • Physical appearance • Posture • Gestures • Facial expression • Eye contact • Voice • Touch • Closing the interview

Interviewing People With Special Needs The Interview • Hearing-impaired people • Acutely ill people • People under the influence of street drugs or alcohol • Personal questions • Sexually aggressive people • Crying • Anger • Threat of violence • Anxiety

Cross-Cultural Communication The Interview • Cultural perspectives on professional interactions • Etiquette • Space and distance • Cultural considerations on gender and sexual orientation Slide 4-7

Overcoming Communication Barriers The Interview • Working with (and without) an interpreter • Nonverbal cross-cultural communication • Vocal cues (and silence) • Action cues • Object cues • Use of personal and territorial space • Touch Slide 4-8

Translation Software / Applications

Observations • Body language Argyle, using video tapes shown to the subjects, analyzed the communication of submissive/dominant attitude and found that non-verbal cues had 4.3 times the effect of verbal cues. Argyle, M, Salter, V., Nicholson, H.,W illiams, M. & Burgess, P. (1970): The communication of inferior and superior attitudes by verbal and non-verbal signals. British Journal of Social and Clinical Psychology 9: 222-231.

Observations • Body language

Observations • Body Language A)”Hmm… How long did they say block 2.0 lasts?”

Observations • Body Language 2. “Power Point could be the miracle cure for insomnia..”

Observations • Body Language

Observations • Body language

Observations Healthcare Provider Body Language

How to terminate the interview • If the session has been long, give a warning • As the person to summarize their primary concerns • Ask if there are other areas to be discussed • Offer yourself as a resource • Explain routines and provide information about who does what • End on a positive note

Interviewing & Documentation