Patient InterviewPatient Interview

ComponentsComponents

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

Description of general healthDescription of lifestyleChanges in status since last visitAll info is considered confidential!!

6 C’s6 C’s

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

Client’s words in quotation mark’sClarityCompletenessConciseChronologicalConfidentiality

Tips for successful interviewTips for successful interview

Private area without interruptionsDevelop 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

Effective questioningEffective questioning

Open-endedHypothetical questionsMirroring responseFocusing on pt.Encouraging pt. to take leadEncouraging pt. to evaluate his/her

situation

Ineffective questioningIneffective questioning

Closed-ended questionsLeading questionsChallengingProbingAgreeing or disagreeing

Examination of pt.Examination of pt.

Methods include: inspection, palpation, percussion, auscultation, mensuration, manipulation

Components of general physical Components of general physical examexam

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

Exam cont.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 cont.

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 cont.

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

Components of tx planComponents of tx plan

Symptoms: Objective and subjectiveDiagnostic tests and their resultsPlan of action: meds, therapies, surgeries,

diet, activity levelDocumentation of result of txModification of planPt. education

SOAPIERSOAPIER

S- subjective symptoms (pt. says)O- objective sx (can be seen or measured)A-assessment, dxP- plan (tx plan)I- Implementation (putting plan in action)E- evaluation (results of plan)R-revision (change plan based on

evaluation)

Sample treatment planSample 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

Treatment plan cont.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)