The Health History and Interviewing Process
Laura Robbins-Frank MSN, RNC, APN
Building a History
A good history through effective interviewing is the key to understanding and lays the foundation for good care.
Importance of the History and Physical Examination
Diagnosis is made from History--- >70% Physical--- <20% Labs/Tests--- <10%
Building a History
Building a history versus taking a history What is required to build a history and relationship with a patient?
Effective Communication
Nonverbal behavior rapport eye contact movements body position, space touch physiologic parameters (breathing, flushing, sweating)
Effective Communication
Enhancing Patient Reponses Use: open-ended questions Avoid/limit: close-ended questions leading questions multiple questions
Effective Communication
Facilitation Non-questioning comments/remarks I see, Go on, Tell me more, Ummm Reflection Body language Nods, eye contact, leaning forward Silence
Effective Communication
Refocusing Use if patient is rambling, scattered, covering many problems at one time Summarizing Allows you to check your understanding of the history for accuracy Clarifies the patients perspective
Common Traps in Interviewing
Failure to get the overall picture first Premature focusing on details Accepting vague or ambiguous answers Providing false reassurance Giving advice
Common Traps in Interviewing
Using authority Using professional jargon Using leading or biased questions Interrupting or talking to much Using why questions
Components of the Complete Health History
Identifying Information/Patient Profile Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Family History (FH) Personal and Social History (SH) Review of Systems (ROS) **All of the health history is
Identifying Information/ Patient Profile
Name Date Time Age Gender Race Occupation Source and reliability of source
Chief Complaint
The major reason for the encounter as expressed by the patient; includes duration A direct quote is preferable Not a diagnosis
History of Present Illness
A clear chronological narrative account of the problem(s) for which the patient is seeking care. Classify symptoms into 8 dimensions: L: Location- point to spot, radiation? O: Onset- setting in which symptom occurred, where? C: Characteristics- dull, sharp, burning, crampy, etc S: Severity- graded on a 1 to 10 scale T: Timing- duration, frequency, pattern? A: Aggravating and Alleviating factors- what makes it better? what makes it worse? A: Associated symptoms- includes significant negatives M: Meaning to patient
Past Medical History
General healthas the patient perceives it Childhood illnesses Adult illnesses Psychiatric illnesses Immunizations Surgery Serious injuries (and resulting disability) Medications Allergies (and reactions) Transfusions Recent screening tests Obstetric/Gynec ologic history
Family History
At least a three generation analysis for significant diseases that tend to have a familial or genetic base. Record age and health or age and cause of death Ask about heart disease, high blood pressure, cancer, stroke, sickle cell disease, diabetes Others listed on page 18 in textbook
Personal and Social History
An outline or narrative description capturing the most important things about the patient as a person
Habits- tobacco, caffeine, ETOH, drugs Diet Sleep Exercise
Self Care/Safety Measures
Sexual History Home Conditions Occupation Environmental Hazards Military Record Religious and Cultural Preferences Access to Care
Review of Systems
A specific review of each body system to identify the presence or absence of health related issues Ask about common symptoms in each system Record negative and positive findings
Concluding the Interview
Summarize the patients chief complaint or problem Ask: Is there anything else that you want me to know? Is there anything else that we should discuss today?
Complete Most comprehensive Usually done the first time you see a patient Focused History Done for an acute problem Only components of the history and physical examination that relate to the chief complaint are done Interim History Chronicles events since last visit Usually a follow-up visit
Types of Health Histories
Subjective vs Objective
Data
Remember! The health history is subjective information- it is information the patient is telling you. The physical examination is objective information- it is information you observe on the patient.
Mr. Garcia
Your Mission
Obtain a complete health history on a client outside of class (must be at least 50 years old) Use format in this lecture and on BB History must be typed, 11-12 pt font Do not put clients name- use initials! More Information will be forthcoming- this will not be due until much later in the semester
