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PHA 3785 Therapeutic Communication and Health History. Debra A. Allan Danforth, MS, ARNP, FAANP FAMU College of Pharmacy 12/10. Legal and Ethical Issues. Legal refers to action or inactions that may be held accountable by law, particularly criminally, and also civil

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pha 3785 therapeutic communication and health history

PHA 3785Therapeutic Communicationand Health History

Debra A. Allan Danforth,


FAMU College of Pharmacy


legal and ethical issues
Legal and Ethical Issues
  • Legal refers to action or inactions that may be held accountable by law, particularly criminally, and also civil
  • Ethics moral principles or standards of conduct, and may be held accountable in civil court
legal and ethical issues1
Legal and Ethical Issues
  • Autonomy
  • Beneficence
  • Nonmaleficence
  • Utilitarianism
  • Fairness and justice
  • Deontologic imperatives
  • Refers to the individual and their affairs (Ex. The right to be left alone)
    • Person’s name
    • Invasion of privacy
    • Breach of confidentiality
    • Autonomy
what is assessment
What Is Assessment?
  • A data collection process
  • A continuous process
  • Establishes a baseline
  • A systematic process
  • Identifies patients’ strengths and


  • Involves collecting, validating, and

clustering data

purpose of assessment
Purpose of Assessment
  • Collect pertinent patient health status data
  • Identify abnormal findings
  • Identify patients’ strengths and coping resources
  • Pinpoint actual health problems
  • Identify risk factors for health problems
assessment skills
Assessment Skills

Cognitive Skills

Assessment is a “thinking process”

  • Inductive and deductive reasoning
    • Ex. Inductive: used when assessing a post-op patient who state it hurts to take a deep breath
      • Piece together pertinent data
    • Ex Deductive: patient is admitted to hospital with CHF. Will look for specific signs and symptoms as you perform the assessment and determines patient’s response to illness
      • Looking for specific clues to support
  • Clinical decision making
assessment skills1
Assessment Skills

Problem solving

  • Reflexive thinking
    • Is automatic, without conscious deliberations and comes with experience
  • Trial and error
    • Is hit or miss thinking-random, not systematic and inefficient
  • Scientific method
    • Is a systematic, critical thinking approach to problem solving
  • Intuition
    • Is a problem-solving method that develops through experience
assessment skills2
Assessment Skills

Psychomotor Skills

Assessment is a “doing” process

  • Skills needed to perform the 4 techniques of physical assessment
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
assessment skills3
Assessment Skills
  • Interpersonal/Affective Skills

Assessment is a “feeling” process

  • Affective skills needed to develop caring, therapeutic healthcare provider-patient


    • Include verbal and nonverbal
    • Establish trust and mutual respect
assessment skills4
Assessment Skills

Ethical Skills

Assessment is being responsible and accountable

  • Responsible & accountable for practice
  • patient advocate
  • Respect patients’ rights
  • Assure confidentiality
types of assessment
Types of Assessment
  • Comprehensive
  • Ongoing/Partial
  • Problem focused
  • Emergency
types of data
Types of Data
  • Subjective
    • Definition: Of, relating to, or designating a symptom or condition perceived by the patient and not by the examiner.
  • Objective
    • Definition: Indicating a symptom or condition perceived as a sign of disease by someone other than the person affected.
identify subjective or objective
Identify Subjective or Objective
  • Headache
  • BP 170/110
  • Nausea
  • Diaphoresis
  • Equal pupil reaction
  • Dizziness
  • Slurred speech
  • Numbness in left arm
central objectives of interacting with a patient
Central Objectives of Interacting with a patient
  • To find out what is at the root of that person’s concern
  • To help them in doing something about
  • What does a patient need?
  • What is the patient worried about?
  • What does the patient expect of you?
history and physical
History and Physical
  • The heart of the diagnosis and treatment process
  • Must be done in an orderly process
  • Must also be sensitive to the “soft” cues that are almost always there
goals of patient interview
Goals of Patient Interview
  • Information discovery
  • Providing information to the patient
  • Negotiating with the patient regarding treatment management
  • Counseling regarding disease prevention
ineffectiveness of most communication
Ineffectiveness of Most Communication
  • Most people do not communicate well
  • Causes an interpersonal gap and isolates people from each other
communication barriers
Communication Barriers
  • A barrier to communication is something that keeps meanings from meeting
  • Without realizing, people typically inject communication barriers over 90% of the time when one or both parties has a problem to be dealt with or a need to be fulfilled
why are they high risk responses
Why are they High-Risk Responses?
  • They block conversation
  • Increase emotional distance between people
  • Thwart the other person’s problem-solving efficiency
categories of barriers
Categories of Barriers
  • The “Dirty Dozen” of barriers to communication can be divided into three major categories
    • Judging
    • Sending Solutions
    • Avoiding Other’s Concerns
  • Criticizing
  • Name-calling
  • Diagnosing
sending solutions
Sending Solutions
  • Ordering
  • Threatening
  • Moralizing
  • Excessive/Inappropriate Questioning
  • Advising
avoiding the other s concerns
Avoiding the Other’s Concerns
  • Diverting
  • Logical Argument
  • Reassuring
listening more than merely hearing
Listening: More Than Merely Hearing
  • Listening refers to a more complex psychological procedure involving interpreting and understanding the significance of the sensory experience
listening skill clusters
Attending Skills

A posture of involvement

Appropriate body motion

Eye contact

Nondistracting environment

Listening Skill Clusters
listening skill clusters1
Following Skills

Door openers

Minimal encouragers

Infrequent questions

Attentive silence

Listening Skill Clusters
listening skill clusters2

Reflecting feelings

Reflecting meanings

Summative reflections

Listening Skill Clusters
  • Reflecting Skills
  • Concise response
  • Essence of content
  • Listener’s own word
reflecting feelings
Reflecting Feelings
  • Improve capacity to “hear” feelings
  • Listening for feeling words
  • Inferring feelings from the overall content
  • Observing body language
  • “What would I be feeling?”
reflecting meanings
Reflecting Meanings
  • “You feel…because”
  • Validation of Data
    • Using technical terms
    • Not allowing patient to finish answer
    • Too many questions
    • Failure to find out patient’s interpretation
summative reflections
Summative Reflections
  • Brief restatement of main themes and feelings speaker expressed
  • Gives speaker feeling of movement in exploring content and feeling
interview communication techniques
Open Ended Questions

Closed Questions





Active Listening






Sharing Perception


Sequencing Events


Presenting Reality


Interview –Communication Techniques
open end questions
Open End Questions
  • Advantages
    • Elicits a response
    • Effective in stimulating descriptive or comparative responses
    • Allows patient to disclose information when he/she is ready
    • Provides clues to alertness, level of mental abilities, organization of thought through vocabulary
    • Rapport is strengthened
open end questions1
Open End Questions
  • Disadvantages
    • Response not relevant
    • Digress to avoid disturbing data
    • Anxiety increased if not articulated
closed questions

Requires no more than 1-2 words

Used more initial interview


Limits answers

Closed Questions
affirmation facilitation
  • Acknowledge patient’s response through verbal and nonverbal response
  • Reassures you are listening
  • Nodding, sitting up and leaning forward are nonverbal ques
  • Verbal cues
    • “ah ha”, “go on”, “tell me more”
  • Silence allows patient to collect thoughts before responding and help prevent hasty responses
  • More uncomfortable for interviewer than interviewee
  • Gives interviewer time to think and plan response
  • Focus on patient’s nonverbal behavior
  • If unsure or confused what patient says, rephrase
    • “let’s me see if I have this right”
    • “ I’m not sure what you mean”
  • Restating the main idea shows the patient that you are listening, allows acknowledgement of feelings, and encourages further discussion
  • Also helps to clarify and validate what your patient has said and may help identify teaching needs
    • “I take a water pill every day for my blood pressure”
      • “I see you take Lasix for your blood pressure”
    • “NO, I take a water pill”
active listening
Active Listening
  • Pay attention
  • Eye contact
  • Listen to what patient tell you both verbally and nonverbally
  • Conveys interest and acceptance
  • Watch your own body language
  • Acknowledge patient’s feelings
    • “I’m afraid of having surgery”
      • “You’re afraid of having surgery?”
  • Encourage further discussion
  • Can be very therapeutic
  • Reduces anxiety
  • Helps to cope more effectively
  • Puts things into perspective
  • Decreases social distance
  • Giving information helps the patient with making decisions on their healthcare
    • Teaching pre-operatively how to do a procedure post-operative like coughing and deep breathing can help the patient in the long run
  • Helps to keep communication


  • To get back on track
    • “Getting back to what brought you to the clinic…”
  • Allows to hone in on a specific area
  • Encourages further discussion
    • “Do you do SBE?”
    • “Have you had a MMG?”
    • “Do you do a testicular exam?”
  • Presenting alternative ideas gives your patient options
  • Helpful if patient is having difficulty verbalizing feelings
  • Good teaching tool
    • “I’ve tried to lose weight and I can’t”
      • “Have you tried diet and exercise”
  • Useful conclusion
  • Allows patient to clarify any misconceptions
    • “let me see if I have this correct”
how to demonstrate respect for patient
How to Demonstrate Respect for Patient
  • Introduce yourself clearly and explain your role
  • Do not use patient’s first name during initial interview without permission
  • Inquire about and arrange for patient comfort before getting started and during
  • Warn patient when going to perform something painful or unexpected
  • Respond to the patient that shows you have heard what they have said
  • Be open, honest, and sincere
  • Can detect a less-than honest response or inconsistencies between verbal and nonverbal behavior
  • The ability to be yourself in a relationship despite your professional role
    • “introduce yourself as a nursing student, pharmacy student, nurse practitioner, pharmacist, etc.”
  • Sensitive and accurate understanding of the person’s feeling while maintaining a certain separateness from the individual
  • Understanding the situation that contributed to or “triggered” the feelings
  • Communicating with the other in such a way that the other feels accepted and understood
patient centered clinical method
Patient-Centered Clinical Method
  • What does it mean to be patient-centered?
    • It means much more than merely being “nice” or “kind” or “compassionate” to the patient.
patient centered clinical method1
Patient-Centered Clinical Method
  • Is an evidenced-based, conceptual method of practice consisting of the following interactive components:
    • Exploring both the objective disease processes and the patient’s subjective illness experience
    • Striving to understand the whole person and how the illness impacts their life and how their life context influences risks for and responses to disease
    • Finding common ground between the pharmacist perspective and understanding and that of the patient as it relates to the problem, treatment, and expectations
patient centered clinical method2
Patient-Centered Clinical Method
  • Shared decisions about how best to approach the patient’s problem
  • Finding opportunities to incorporate prevention and health promotion into the process of care
  • Recognizing that the patient-pharmacist relationship is a powerful resource and essential to the health and well-being of both participants in the relationship
relationship building
Relationship Building
  • Introduce yourself and explain your role
    • ie: Patricia Dee, 5th year pharmacist student
  • Using polite forms of address
    • ie: Mr., Mrs., Ms., Dr.
  • Listening Attentively
    • Establish eye contact
    • Assume an attentive body posture
    • Establish a comfortable spatial position and distance
    • Minimize distracting behaviors like excessive note-taking or reading and talking at the same time
    • Use summary statement
relationship building skills
Relationship Building Skills
  • P - partnership
  • E- empathy
  • A- apology
  • R- respect
  • L- legitimation
  • S- support
  • Partnership – explicit statement to the patient indicating your willingness to work together in an effort to accomplish therapeutic goals
    • If you would like I’d be happy to review the plan with you to see if any adjustments need to be made.
  • Empathy – capacity to recognize a patient’s feelings or emotional reactions
    • I know it must be frustrating for you to be on this diet and not see much progress.
  • Apology – willingness and ability to acknowledge to another person that you may be in part responsible for a negative outcome, discomfort, ill feelings, etc.
    • I’m sorry if I gave you the impression that I didn’t think you were trying to watch your weight.
  • Respect – willingness to consider another person “worthy of regard”; show respect for another person by being non-judgmental and setting aside personal feelings in order to be helpful and caring
    • I admire you for continuing to make the effort.
  • Legitimation – intervention that explicitly communicates acceptance of the patient’s affect or feelings
    • I think most people would feel frustrated and want to give up.
  • Support – explicit statement conveying your willingness to be available to the patient in a helping capacity
    • Please let me know if there is anything that I can do.
non verbal communication
Non-Verbal Communication

Non-verbal SOFTEN Skills: Listening is as important as

speaking and these non-verbal skills facilitate the

demonstration of active listening.

  • S- smile
  • O- open posture
  • F- forward lean
  • T- touch (caring, reassuring)
  • E- eye contact
  • N- nod
practical points for history taking
Practical Points for History Taking
  • Use a quiet, sympathetic but confident tone of voice
  • Make your questions simple and brief
  • Allow plenty of time for patient to express or explain, before you clarify or continue
  • Clarify inconsistencies between sources or interpretations in non-threatening or non-persecuting manner
practical points for history taking1
Practical Points for History Taking
  • Avoid asking patient for information that they are not likely to have as this can increase anxiety or mistrust about unknown
  • Ask only appropriate questions
  • Use terminology appropriate to their social, cultural and educational status
  • Use significant others, when present, to clarify points that seem to be vague
  • If a child is distracting, provide attention devices
  • Leading the patient
    • People will tell you what you want to hear
    • Do not lead the patient
    • Let them tell you in their own words
  • Biasing yourself
    • Because of the patient, disease or health care provider
  • Letting family members answer for patient
    • Need to let patient answer questions
  • Asking more than one question at a time
  • Not allowing enough response time
  • Using medical jargon
  • Assuming rather than clarifying/validating
  • Taking the patient’s response personally
  • Feeling personally uncomfortable
  • Using clichés
  • Offering false reassurance
  • Asking persistent or probing questions
  • Changing the subject
  • Taking things literally
  • Giving advise
  • Jumping to conclusions
  • Data Collection
    • Omission of pertinent questions
    • Omission of pertinent negatives
    • Failure to elicit temporal relationships precisely
    • Failure to elicit follow-up important leads
  • Structure
    • Beginning too fast
    • Allow patient to ramble
    • Needless repetition of questions
    • Poor transitions
    • Covering delicate areas too early
  • Practitioner Attitude
    • Acting too friendly or not friendly enough
    • Not listening
      • Lack of eye contact
    • Not enough interest or too much interest in emotional factors
phases of the interview
Phases of the Interview
  • Introductory
    • Is the time to introduce yourself to the patient, purpose of the interview and the time frame needed to complete
  • Working
    • Where data is collected, very structured, and the longest phase.
    • Need to listen what is said verbally/nonverbally
  • Termination
    • Need to summarize and restate findings
components of the health history
Components of the Health History
  • Identifying info
  • Chief Complaint or Chief Concern (CC)
  • History of Present Illness (HPI)
  • Functional History (FxH)
  • Past medical history (PMH)
  • Family history (FH)
  • Personal and Social (SH)
  • Review of systems (ROS)
biographical data


Phone Number

Social Security #

Contact Person

Age (Birth Date)




Marital Status

Number of Dependents

Educational Level



Advance Directive


Biographical Data
identifying info

Age (Birth Date)


Identifying Info
chief complaint concern for seeking healthcare
Chief Complaint/Concern for Seeking Healthcare

What can the patient’s reasons for seeking health care and the patient’s current health status tell you?

current health status present problem or illness
Current Health Status/Present Problem or Illness
  • Primary Level
    • Usual state of health
    • Any major health patterns
    • Unusual patterns of health care
    • Any health concerns
  • Secondary and Tertiary
    • Perform a Symptom of Analysis (AOS)
symptom analysis
Symptom Analysis

P = Precipitating / palliative factors

Q = Quality / quantity of symptom

R = Region / radiation / related symptoms

S = Severity

T = Timing

symptom analysis1
O: Onset

L: Location

D: Duration

C: Character

A Aggravating/Associate


R: Relieving Factors

T: Temporal Factors

S: Severity

O: Onset

L: Location

D: Duration

C: Character

A: Aggravating/Associate


R: Related symptoms

T: Treatment

S: Severity

Symptom Analysis
analysis of symptoms sacred 7
chief concern








Progression over time


Aggravating Factors

Relieving Factors

Associated Symptoms

Similar symptoms in past

Explanation why concern presented now

Theories or worries about causes / implications

Impact of symptoms

Analysis of Symptoms “Sacred 7”
functional assessment
Functional Assessment
  • Activity of Daily Living (ADL’s)
    • Dressing, Grooming, Feeding, Bathing
  • Instrumental Activities of Daily Living (IADL’s)
    • Driving, Cooking, Using medication
  • Advanced Activities of Daily Living (AADL’s)
    • Work, Church, Recreations
functional history
Functional History
  • ADLs; one’s basic personal care
    • Listed in order of hardest to easiest to perform
    • Minimum requirement to live home alone
    • Represent primarily physical ability
    • Acquired by the first time one leaves home (about 6 years old; off to kindergarten)
  • IADLs; one’s ability to manage home life for them self
    • Represent cognitive component in addition to physical ability
    • Acquired by the second time one leaves home (about 16 years; off to college, career, etc.; the things mom and dad won’t be doing now)
  • AADLs; what makes life meaningful, not necessarily essential for survival (as ADLs and IADLs are)
    • Often correlate with quality of life measures
past medical history
General Health and Strength

Major Adult Illness


Psychiatric conditions








Serious Injuries/Accidents


Childhood Illness

Menstrual Cycle (females only)



Blood pressure




Stool for occult blood



Past Medical History
family history




Spouse/Significant other


Family History
personal and social history

Marital Status

Home condition


Military record

Cost of Care

Sexual History

Domestic Violence

Living Will/ Healthcare surrogate




Recreational Drugs


Sleep and Rest

Nutrition and diet

Coffee, Tea

Special Diet

Religious preference

Cultural Requirement

Personal and Social History
assessment of domestic violence
Assessment of Domestic Violence
  • HITS (Sherin et al, 1998)
    • H Hurt you physically?
    • I Insult or talk down to you?
    • T Threaten you with physical harm?
    • S Scream or curse at you?
assessment of exercise
Assessment of Exercise
  • FIT acronym to ask about exercise regimen
    • F is for FREQUENCY of the activity
    • I is for the INTENSITY of the activity
    • T is for the TIMING, or duration, of the activity
assessment of substance abuse
Assessment of Substance Abuse
  • Abuse of alcohol and other substances is a highly prevalent problem
  • Healthcare providers must assess for such behaviors because of implications for complications of illness
  • Two types of tools used to assess alcoholism
    • CAGE
    • TACE
  • The history of alcohol consumption and dependency can further be assessed by using the questionnaires
    • HALT
    • BUMP
    • FATAL DT
  • C: Are you CONCERNED about your drinking?
  • A: Are you ever ANNOYED when someone questions the amount you drink?
  • G: Do you ever feel GUILTY about your drinking?
  • E: Do you feel you need an EYE-OPENER in the a.m.?
  • T: How many drinks does it TAKE to make you feel high?
  • A: Have people ANNOYED you by criticizing your drinking?
  • C: Have you felt you ought to CUT down?
  • E: Do you feel you need an EYE-OPENER in the a.m.?
  • H Do you usually drink to get HIGH?
  • A Do you drink ALONE?
  • L Do you ever find yourself LOOKING

forward to drinking?

  • T Have you noticed whether you

seem to be becoming TOLERANT

of alcohol?

  • B “Have you ever had BLACKOUTS?”
  • U “Have you ever used alcohol in an


  • M “Do you ever drink alcohol for MEDICINAL reasons?
  • P “Do you find yourself PROTECTING your supply of alcohol?”
fatal dt
  • F “Is there a FAMILY history of alcoholic problems?”
  • A “Have you ever been a member of ALCOHOLICS Anonymous?”
  • T “Do you THINK you are an alcoholic?”
  • A “Have you ever ATTEMPTED or had thoughts of suicide?”
  • L “Have you ever had any LEGAL problems related to alcohol consumption?”
  • D “Do you ever DRIVE while intoxicated?”
  • T “Do you ever use TRANQUILIZERS to steady your nerves?”
review of systems
General Health Survey







Head and Neck



Nose and Sinuses

Mouth and Throat

Review of Systems
review of systems1





Female Reproductive

Male Reproductive






Review of Systems
physical exam
Physical Exam
  • General appearance
  • Vital signs
  • Head, neck
  • Eyes, ears
  • Chest, pulmonary
  • Heart, peripheral vascular
  • Skin
  • Abdominal
  • Musculoskeletal
  • Mental status
  • Neurological
  • Female genital, breast
  • Male genital, rectal
  • SOAP
  • DAR
  • PIE
  • Narrative
  • Electronic Medical Records
  • Be accurate and objective.
  • Use acceptable abbreviations.
  • Be brief and to the point.
  • Document in short phrases.
  • Avoid “normal, usual, general, unremarkable”
  • Record pertinent negatives.
  • Include all required components
    • Include only subjective in S
    • Include only objective in O
  • Associate each plan with corresponding assessment
  • Date and sign documentation.
  • Definition: Of, relating to, or designating a symptom or condition perceived by the patient and not by the examiner.
    • Begins with chief concern
    • Includes all of HPI
    • Portions of Functional history
    • Portions of PMH
    • Pertinent SH, FH
    • Pertinent ROS
  • Definition: Indicating a symptom or condition perceived as a sign of disease by someone other than the person affected.
    • Begins with general observations
    • Includes vital signs
    • Includes systems based exam based on symptoms and understanding of anatomy/physiology/pathology
    • Diagnostic data: laboratory, x-ray, etc.
sample soap note with errors
Sample SOAP Note (With Errors)


Cc: “she says she has a sore throat”

51 year old female appears her stated age, alert, cooperative in no acute distress. Patient was well until 2 days ago when she awoke and noticed a sore throat, progressively worse throughout the day. Pain is constant, “scratchy” ache, rated 4/10, and radiates to the right ear with swallowing. Pain is aggravated by swallowing; relieved with salt water gargles and Chloraseptic spray.


Temp 98.7 F but she says she felt hot, PR 60 bpm, RR 14 bpm, BP sitting R arm 110/70

Throat: she says she has a lump in her throat; tongue not coated, uvula midline without ulcerations, tonsils prominent with erythema but no exudates

Lungs: clear to auscultation without wheezing


She’s worried this is Strep throat


Diagnostic tests: throat culture

Treatment: patient asked for antibiotics

Patient education: Associates degree in information technology

sample soap note
Sample SOAP Note


Cc: “My throat is really sore”

Patient was well until 2 days ago when she awoke and noticed a sore throat, progressively

worse throughout the day. Pain is constant, “scratchy” ache, rated 4/10, and radiates to the

right ear with swallowing. Pain is aggravated by swallowing; relieved with salt water gargles and

Chloraseptic spray. She reports feeling hot but has not measured her temperature and feels the sensation of

lump in her throat, mostly on the right side. She believes this could be Strep throat and is concerned she is

contagious to others. She has a history of Strep throat in high school with similar symptoms.


51 year old female appears her stated age, well developed, well nourished, alert, cooperative in no acute

Distress with no notable characteristics.

Temp 98.7 F (orally), PR 60 beat per minute, RR 14 breaths per minute, BP sitting R arm 110/70mmHg

Throat: tongue not coated, uvula midline without ulcerations, tonsils prominent with erythema but no exudates

Lungs: clear to auscultation without wheezing


1. Possible Strep throat

2. Medication renewal: Synthroid


1. Diagnostic tests: throat culture

Treatment: antibiotics if throat culture positive

Patient education: medication schedule, change toothbrush, encourage oral hydration

2. Diagnostic tests: blood TSH level in 6 months

Treatment: Synthroid 100mcg po qd Disp 30 day supply with 5 refills

Patient education: review symptoms of hypo and hyperthyroidism