Health Assessment INTERVIEWING & THE HEALTH HISTORY Dr. Issa Hweidi, RN MSN, DNSc

“Just the facts sir...?” A good history through effective interviewing is the key to understanding and lays the foundation for good care

THREE FUNCTIONS OF INTERVIEWING *INFORMATION GATHERING *BEHAVIOR MANAGEMENT *EMOTION ATTENDING

INFORMATION GATHERING Objectives Accurate data Efficient collection

BEHAVIOR MANAGEMENT Objectives Medication/treatment adherence Lifestyle change Increased coping skills

EMOTION ATTENDING Objectives Reduced interference Relief of distress Patient satisfaction Detection Improved physical health Provider’s own satisfaction

INFORMATION GATHERING Skills 1) Nonverbal behavior *rapport *eye contact *movements *body position, space, change *touch *physiologic parameters (breathing, flushing, sweating)

INFO GATHERING SKILLS (CONT) 2) Questioning Behavior *Opening *Open-ended questions *Closed-ended questions *Leading questions *Multiple questions 3) Facilitation *Non-questioning remarks “I see...,” “Go on...,” “Tell me more...,” “Umm hum...” *Reflection *Nods, grunts *Eye contact *Silence

INFO GATHERING SKILLS (CONT) 4) Direction/Refocusing *Polite but firm 5) Summarizing *Check accuracy *Patient’s perspective

BEHAVIOR MANAGEMENT Skills 1) Education *Explanation *Instruction 2) Motivation *Authority/modeling *Attribution *Rehearsal *Affirmation of intent

EMOTION ATTENDING Skills 1) Nonverbal behavior *Flexibility *Touch 2) Empathy *Demonstrates a sense of patient’s experience *Limited self disclosure 3) Respect *Acknowledgment of uniqueness of the problem 4) Support

EMOTION ATTENDING (CONT) 5) Confrontation 6) Interpretation 7) Reassurance *Understandability of client’s feelings *Time limitedness

COMMON TRAPS IN INTERVIEWING 1) Failure to get overall picture first 2) Premature focusing on details 3) Accepting vague or ambiguous answers 4) Providing false reassurance 5) Giving advice 6) Using authority 7) Using professional jargon 8) Using leading or biased questions 9) Interrupting/talking too much 10) Using “WHY” questions

Components of the Complete Health History Identifying Information/Patient Profile Chief Complaint Present Illness Past History Current Health Status Family History Psychosocial History Review of Systems

S.O.A.P. NOTES S = Subjective -- information given by the patient, or by family members and significant others O = Objective -- physical findings and laboratory reports A = Assessment -- differential diagnosis, thoughts about what might be going on P = Plan -- how you and the patient will proceed...therapies, advice, self-care, behavior change, etc.

Health History Components Identifying Information/Patient Profile -- include info such as name, age, sex, race, birthplace, marital status, occupation, religion, source of referral, source and reliability of information Chief Complaint/CC -- the major reason for the encounter as expressed by the patient; includes duration. A direct quote is preferable. NOT A DIAGNOSIS.

Health History Components (cont) Present Illness/HPI -- clear, chronological narrative account of the problem(s) for which the patient is seeking care. Classify symptoms into 8 dimensions: (Lots Of Care Says Take All Appropriate Measures.) L - location; point to spot; radiate? O - onset: setting in which symptom occurred. Where, doing what... C - character: dull, sharp, burning, crampy... S - severity: grade on scale 1-10; worse? better? same? T - timing/chronology: duration? frequency? pattern A - aggravating and alleviating factors A - associated symptoms; include significant negatives. M - meaning of symptom to patient.

Health History Components (cont) Past History/PMH -- –General Health - as the patient perceives it –Childhood Illnesses –Adult Illnesses –Psychiatric Illnesses –Accidents/Injuries –Surgical Procedures –Hospitalizations (not already described) –Obstetrical history –Transfusions

Health History Components (cont) Current Health Status -- –Current Medications –Allergies –Immunizations –Screening Tests –Habits - tobacco, coffee, alcohol, drugs –Diet –Sleep –Exercise and Leisure Activities –Environmental Hazards –Safety Measures

Health History Components (cont) Family History/FH -- usually a one or two generation analysis for significant diseases that tend to have a familial distribution, e.g. –diabetes –hypertension –cancer –heart disease –bleeding disorders –sickle cell anemia –stroke –long exposure to diseases such as tuberculosis Include a description of illnesses of family members that contain a psychological impact on the patient, a congenital influence, a genetic factor or symptoms like those of the patient.

Family History

Health History Components (cont) Psychosocial History -- an outline or narrative description capturing the most important things about the patient as a person –Home Situation and Significant Others –Daily Life –Important Experiences –Religious Beliefs –The Patient’s Outlook

Health History Components (cont) Review of Systems/ROS -- a specific review of each body system from head to toe. Ask about common symptoms in each system to identify problems the patient has not mentioned. Areas often overlooked in ROS are: –neurological –hematological –endocrine Use combination of open-ended and direct questions –ROS is Subjective Information

Episodic vs. Complete History Episodic History is chief complaint related Contains same components as complete history but more abbreviated HPI includes PMH and ROS related to the CC May still have a PMH section to cover any other major episodes or ongoing problems