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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.

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Interviewing documentation

Interviewing & Documentation

The Nursing interview

J. Carley MSN,MA, RN, CNE

Fall, 2009


Interviewing documentation1

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 nursing interview

The Nursing Interview

Not!


The nursing interview more like this

The Nursing Interview…More Like This!


The interview

The Interview

The Interview

  • Subjective data

  • Results of a successful interview

  • The interview as a contract between patient and examiner

    • Time and place


The interview1

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 interview2

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 interview3

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 interview4

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 interview5

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

Process of Communication

The Interview

  • Sending

You are most aware of

Verbal communication: words, voice

Inflection / tone.

Be aware of the Non-verbals

that you send as well! Work on them.


Process of communication1

Process of Communication

The Interview

  • Sending

  • Receiving

    Context gives meaning to the messages you send.


Process of communication2

Process of Communication

The Interview

  • Sending

  • Receiving

  • Internal factors

    • Liking others

    • Empathy

    • Ability to listen

LISTENING

is not a passive process


Process of communication3

The Interview

Process of Communication

  • External factors

    • Ensure privacy

    • Refuse interruptions

    • Physical environment

    • Dress (Attire & Condition)

    • Note-taking

    • Tape and video recording


Establish rapport

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

Begin the Interview

  • Give your name and position

  • Verify the client’s name

  • Briefly explain your purpose


Techniques of communication

Techniques of Communication

The Interview

  • Introducing the interview

  • Working phase

    • Open-ended questions

    • Closed or direct questions


Techniques of communication1

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


Techniques of communication2

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


Techniques of communication3

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


Techniques of communication4

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


Techniques of communication5

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


Techniques of communication6

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


Techniques of communication7

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


Techniques of communication8

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


Techniques of communication9

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

http://www.youtube.com/watch?v=gpVjW30I-YU


How to listen

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

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

Observations

  • Carefully assess areas connected to verbal cues

  • Use your senses

  • Note general appearance

  • Observe body language

  • Notice interaction patterns


Techniques of communication10

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 communication11

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

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

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

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


Interviewing documentation

Translation

Software /

Applications


Observations1

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.


Observations2

Observations

  • Body language


Observations3

Observations

  • Body language


Observations4

Observations

  • Body Language

A)”Hmm… How long did they say block 2.0 lasts?”


Observations5

Observations

  • Body Language

2. “Power Point could be the miracle cure for insomnia..”


Observations6

Observations

  • Body Language


Observations7

Observations

  • Body Language


Observations8

Observations

  • Body Language


Observations9

Observations

  • Body language


Observations10

Observations

  • Body language


Observations11

Observations

  • Body language


Observations12

Observations

  • Body language


Observations13

Observations

  • Body language


Observations14

Observations

Healthcare Provider Body Language


How to terminate the interview

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


Charting documentation

Charting & Documentation

  • If it isn’t written, then it wasn’t done

  • Chart at the time it occurs – if possible

  • Follow facility guidelines

  • Is the information clear and logical?

  • Is it true?

  • Is it non - judgmental?

  • Record all abnormals and normals


Charting guidelines

Charting guidelines

  • Be precise

  • Stick to the facts

  • Sign your name after each entry

  • SOAP format – focuses on specific problems

  • AIR, DAR, PIE, DIE formats – focus on nursing interventions and client response

  • Prioritize the client problems


Interviewing documentation2

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


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