1. Health History Interview Social Conversation vs Aim for other’s health improvement Express one’s interest or need. Responsible for oneself

2. Health History Interview 1.Establish trust & supportive relation 2.Gather information 3.Offer information Most value skill of clinical care Much more than just asking a question Objective

3. Techniques promote trust & communication Unfold the patient’s story in detailed form Generate hypothesis about the nature of patient’s concern Test hypothesis by asking more detailed information Explore the patient’s belief and feelings If little can be done, discussing the patient’s experience can be Rx clinical reasoning pt’s perspective Rx

4. Health History Format Structured framework for patient’s information Structured framework for patient’s information Focus clinician’s attention on specific pieces of information Focus clinician’s attention on specific pieces of information Interview Process Generate the piece of information is more fluid Require :  knowledge of information  ability to elicit accurate and detailed information  interpersonal skill  response pt’s feeling Require :  knowledge of information  ability to elicit accurate and detailed information  interpersonal skill  response pt’s feeling usually clinician’s perspectiveInclude patient’s perspective

5. Factors that influent health history 1. Patient’s need and concern 2. Clinician goal of encounter 3. Clinical setting (IPD, OPD, PCU, subspecialty)

6. Getting Ready: the approach to interview Require planning: Take time for self reflection Reviewing the chart Setting goal for the interview Reviewing clinician behavior and appearance Improving the environment Taking note clinician information patient

7. Take time for self reflection Clinician’s challenge: being consistency open and respectful toward Individual differences. is a continual part of professional development in clinical work must look inward to clarify how our own expectation and reaction (value, assumption, bias).

8. Reviewing clinician behavior and appearance Just you observe the patient, the pt. will be watching you. Consciously or not, you sent message through words and behavior. Being sensitive to non-verbal message, should be calm and unhurried, even time limited. Must take pain, not to express negative feeling. Try to consider the pt’s perspective, you want the pt. to trust you

9. Reviewing the chart Goal gather information develop ideas about what to explore should not let the chart prevent you to develop new idea.

10. Setting goal for the interview Student → write up patient’s report Clinician → make healthy balance between provider centered goal patient centered goal institute health insurance family

11. Taking note do not let note taking distract you from pt. jot down specific words, not in format keep eye contact, put down the pen during sensitive feeling when find uncomfortable, explore concern and explain, you need accurate record always keep eye on patient’s feeling

12. Improving the environment sitting distance making privacy and comfortable

13. Learning about the patient’s health devote time fully ready to listen elicit patient’s concern

14. The process of interview Greeting the patient and establish rapport Inviting patient’s story Establish the agenda for interview Expand and clarify the patient’s story Generate and testing diagnostic hypothesis (clinician perspective) Create shared understanding of problems Negotiating a plan Planning to follow up and closing interview

15. Greeting the patient and establish rapport Physical setting shape the patient first impression Greet the patient by name Maintain confidentiality Let the patient decide if third party needed Attune the patient’s comfort Arrange the seat in appropriate distance Spend small talk to put the patient as ease

16. Inviting patient’s story Chief complaint : begin with open question Listen without interrupt, give opportunity to response fully Train yourself to follow the patient’s lead, listen actively, use continuer… go on

17. Establish the agenda for interview The clinician always approach with specific goal in mind, the patient also has specific questions and concerns Identify at the beginning, allow time effectively, make sure you addressed all patient’s issues If many problems…approach the most concerned one…list others…all are important…will be addressed at next visit

18. Expand and clarify the patient’s story Each symptom must be clarified: 7 attributes Location and radiation Quality or charactors Severity Timing: onset, duration, frequency Setting contributed to illness: emotion, trauma, working Remitting or exacerbating factors Associated symptoms

19. Expand and clarify the patient’s story Use understandable language (pt’s word) Facilitate pt’s story by different type of questions Move back and forth from open ended questions to direct question to another open ended question Established sequence and time course Each symptom must be clarified: 7 attributes Location Character Severity Timing Setting Remitting/aggravating Associated symptoms

20. Generate and testing diagnostic hypothesis (clinician perspective) Generate and testing diagnostic hypothesis (clinician perspective) Specific detailed might differentiated one disease from another Built evidence for and against diagnostic possibility Review systems for additional data

21. Create shared understanding of problems “disease” vs. “illness” To understand the patient’s expectation & concern - asking patient-centered questions in 6 domains: the pt’s thought about illness the pt’s feeling, fear the pt’s expectation effects to the pt’s life prior experience Rx response already tried

22. Negotiating a plan Help the patient create complete picture of problems and form a basis for planning further evaluation. Autonomy and voluntariness

23. Planning to follow up and closing interview May find that ending if difficult, if pt. enjoys discussing May close up with summary plan.. take medicine…get blood test and make appointment for next visit. If pt. brings new issue, simply reassure of your interest, make plan to address this problem in future time

24. Facilitate the patient’s story Active listening Adaptive questioning Non-verbal communication Facilitation Echoing Empathic response Validation Reassurance Summarization Highlighting transition

25. Adaptive questioning 1.Direct questioning from general to specific use open-ended question 2. Questioning to elicit graded response 3. Asking a series of questions at one time… 4. Offering multiple choice for answer 5. Clarifying what the patient means

26. Comprehensive Health History Format Date and timing Chief complaint (s) : pt’s words Present illness : including bellowed relevant history Past history: medical, surgical, Ob-Gyn, vaccination, screening for diseases Family history: hereditary, contact diseases, cancer, cause of death, Personal and social history: occupation/school, source of stress, economic, life style, belief, health and safety behavior – diet, exercise, comparative medicine, drugs, alcohol, smoking Review of systems Identifying dataReliability

27. Preparing the physical examination Reflect on your approach to the patient Decide on the scope of examination: comprehensive or focused Choose the examination sequence: head to toe Adjust the lighting and environment: adjust bed, tangential light Promote patient comfortable:

28. Reflect on your approach to the patient Appear calm organize and competent Avoid showing distaste, alarm, or negative reaction Sharing the findings with patient Make sure washing your hand in the presence of patient.

29. Promote patient comfortable: Keep privacy, consider third party Art of draping: visualize one area of the body at a time Keep pt. informed when anticipate discomfort or embarrassment Give instructions at each step Be sensitive to the patient’s feeling, watching facial expression When finished, tell the pt. general impression and what to expect next. Rearrange the environment to the pt’s satisfaction