Patient Interviews
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Transcript of Patient Interviews
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Patient Interviews
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Patient Interview and History Introduction
Initial interview with patient is very important
Patient’s medical and health history is the basis for all treatment rendered by the practitioner
Think of questions that are asked?
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Interviewing SkillsEffective listening
Being aware of nonverbal clues and body language
Using a broad knowledge base
Summarizing to form a general picture
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Interviewing Successfully1) Do your research
before the patient interview
2) Plan the interview
3) Approach the patient and request the interview
4) Make the patient feel at ease
5) Deal with sensitive topics with respect
6) Do not diagnose or give a diagnostic opinion
7) Formulate the general picture
8) Conduct the interview in private without interruptions
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Methods of ChartingMost charting methods
are based on a series of steps to document information
SOAP Method
1) Subjective data: obtained through conversation with patient. Thoughts, feelings, and perceptions
2) Objective data: apparent and measurable. Vital signs and test results
3) Assessment: the physicians diagnosis or impression of the patient’s problem
4) Plan of action: Options for treatment
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Health History Form (1) Personal Data – Name,
Birthday, etc.
(2) Chief Complaint – Main reason patient came to office
(3) History of present Illness – medications taken, pain scale
(4) Past medical History – any and all past and present illnesses and surgeries
(5) Family History – can help lead practitioner to a diagnosis
(6) Social and occupational history – marital status, occupations
(7) Review of symptoms
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The Health History Form
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Activity Time- Procedure 5-1 p. 104- Procedure 5-2 p. 117