interviewing documentation
Download
Skip this Video
Download Presentation
Interviewing & Documentation

Loading in 2 Seconds...

play fullscreen
1 / 55

Interviewing & Documentation - PowerPoint PPT Presentation


  • 130 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Interviewing & Documentation' - ozzie


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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 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

slide37

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

ad