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Patient Interview. Chief complaint- subjective statement regarding most significant symptoms or signs of illness Description of general health Description of lifestyle Changes in status since last visit All info is considered confidential!!. Components.

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Presentation Transcript
components

Chief complaint- subjective statement regarding most significant symptoms or signs of illness

  • Description of general health
  • Description of lifestyle
  • Changes in status since last visit
  • All info is considered confidential!!
Components
6 c s

The interview will become part of a legal document- follow the 6 c’s

  • Client’s words in quotation mark’s
  • Clarity
  • Completeness
  • Concise
  • Chronological
  • Confidentiality
6 C’s
tips for successful interview

Private area without interruptions

  • Develop plan before interview, look up pt. hx, chronic problems, meds etc…
  • Use broad knowledge base- look up diseases, drugs tests, etc.. That you don’t know
Tips for successful interview
effective questioning

Open-ended

  • Hypothetical questions
  • Mirroring response
  • Focusing on pt.
  • Encouraging pt. to take lead
  • Encouraging pt. to evaluate his/her situation
Effective questioning
ineffective questioning

Closed-ended questions

  • Leading questions
  • Challenging
  • Probing
  • Agreeing or disagreeing
Ineffective questioning
components of general physical exam

Neurological: LOC- level of consciousness and orientation to person, place and time. Motor ability- ambulation. Senses, speech, hearing, vision

  • Cardiovascular/pulmonary: characteristics of peripheral(arm/leg) pulses. Characteristics of respirations: shallow, deep, regular, dyspnea, SOB. Breath sounds- crackles/rhonchi, rales, wheezes, diminished, labored. Cough- productive or nonproductive
Components of general physical exam
exam cont

Integumentary: wounds, scars, ecchymosis, contracture, rash, lacerations, decubitus ulcers. Color, temp., surgical incisions, stitches, staples

  • Musculoskeletal: contractures, amputation, deformity, atrophy, ROM, ambulation, fractures, dislocations
  • Gastrointestinal: Abdomen, bowel sounds, nutrition, NG tubes, special diets, I & O
Exam cont.
exam cont1

GYN/Reproductive: Date of LMP, breast self-exam, testicular exam, problems

  • Elimination: Stool- constipation, diarrhea, date of last bowel movement. Urine- voiding, incontinent, dysuria, nocturia, foley catheter, external catheter
Exam cont.
exam cont2

Psychosocial: affect, mood, anxious, angry, conversant, defensive, non-cooperative, combative. Living environment: alone, with spouse, nursing home, etc. Vocation/avocation: jobs, hobbies, interests

Exam cont.
components of tx plan

Symptoms: Objective and subjective

  • Diagnostic tests and their results
  • Plan of action: meds, therapies, surgeries, diet, activity level
  • Documentation of result of tx
  • Modification of plan
  • Pt. education
Components of tx plan
soapier

S- subjective symptoms (pt. says)

  • O- objective sx (can be seen or measured)
  • A-assessment, dx
  • P- plan (tx plan)
  • I- Implementation (putting plan in action)
  • E- evaluation (results of plan)
  • R-revision (change plan based on evaluation)
SOAPIER
sample treatment plan

Diabetes: inability of pancreas to produce enough insulin resulting in lack of sugar available for cell metabolism.

  • Symptoms: polyuria, polydipsia, polyphagia, sudden weight loss
  • Diagnostic tests: Fasting blood sugar, glucose tolerance test
Sample treatment plan
treatment plan cont

Plan of action: insulin SQ, ADA diet, moderate exercise

  • Pt. education: use of glucometer, insulin injections, symptoms and treatment of insulin shock, care of infections, care of feet (prone to develop foot ulcers that can result in amputation)
Treatment plan cont.
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