Patient Interviews

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?

Interviewing SkillsEffective listening

Being aware of nonverbal clues and body language

Using a broad knowledge base

Summarizing to form a general picture

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

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

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

The Health History Form

Activity Time- Procedure 5-1 p. 104- Procedure 5-2 p. 117