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C01 The Medical History and the Interview
Terms in this set (19)
The foundation of comprehensive assessment.
It is a written picture of the patient's perception of his or her past and present health status and how health problems have affected both personal and family lifestyle.
Traditionally, the task of obtaining a patient's complete history has belonged to the . . .
Today, however, complete health histories are taken by . . .
Medical histories from patients with an emphasis on information pertaining to their specialty are obtain by . . .
Respiratory therapists (RTs)
Information from histories . . .
> Provides the foundation for interprofessional communication.
> Identifies the patient's symptoms and changes in those symptoms
> Enables many medical disciplines to collaboratively develop or alter a plan of care.
> Enables to assess the effect of therapeutic interventions and overall progress.
A process of imparting a meaningful message.
A patient interview must . . .
Allow the patient to feel secure and free to discuss personal things.
Whether it is a 5-minute assessment of therapy or a 50-minute extended history.
It is a skill as useful in daily patient care as it is to the person obtaining a comprehensive history.
An art that takes time and experience to develop.
The key to a successful interview and patient rapport.
The ability to project a sense of undivided interest in the patient.
Before entering the room, it is best to:
> Review records or new information
> Prepare equipment and charting materials
> Establishes your professional role
> Asks permission to be involved in the patient's care
> Conveys your interest in the patient
What are the things you need to keep in mind during an introduction in a patient interview?
> Dress and groom professionally.
> Enter with a smile and an unhurried manner.
> State your role and the purpose of your visit, and define the patient's involvement in the interaction.
> Call the patient by name.
Why must we use more formal terms in addressing the patient?
To alert the patient to the importance of the interaction.
Shows your respect for the patient's beliefs, attitudes, and rights and enhances patient rapport.
What are the things you need to keep in mind to project professional conduct in a patient interview?
> Be sure the patient is appropriately covered.
> Position yourself so that eye contact is comfortable for the patient.
> Avoid standing at the foot of the bed or with your hand on the door while you talk with the patient.
> Ask the patient's permission before moving any personal items or making adjustments in the room.
> Remember, the patient's dialogue with you and the patient's medical record are confidential.
> Be honest. Never guess at an answer or information you do not know.
> Make no moral judgments about the patient.
> Be mindful and respectful of cultural, ethnic, religious, and other forms of diversity.
> Expect a patient to have an emotional response to illness and the health care environment and accept that response.
> Adjust the time, length, and content of the interaction to your patient's needs.
What does a relaxed, conversational style of interview does to a patient?
It encourages patients to express their concerns.
A relaxed, conversational style on the part of the health care professional with questions and statements that communicate empathy.
What are the things you need to keep in mind to keep a relaxed, conversational style of a patient interview?
> Expect and accept some periods of silence in a long or first interview.
> Close even the briefest interview by asking if there is anything else the patient needs or wants to discuss and telling the patient when you will return.
In a patient interview, be mindful of what best practices:
> Dress and act professionally.
> Prepare by reviewing relevant records in advance.
> Project a sense of undivided interest.
> Use a relaxed conversational style.
> Respect your patients' beliefs and attitudes.
> Remember to reassure your patients that their conversation with you as well as their medical record are confidential.
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