HISTORY TAKING BSNE I

The purpose of medical practice is to relieve patient suffering. In order to achieve this, one must make a diagnosis to guide therapeutic decisions. Thus to understand each client fully from the reason of seeking care to his/her social class is important This is achieved through patient-centered interview.

Patient interview A primary way of obtaining comprehensive information about the patient in order to provide effective patient-centered care. A methodological approach is used to obtain information from the patient, usually starting with determining the patient’s chief complaint, usually known as the reason of hospital visit.

Interviewing techniques the purpose of the interview is to obtain accurate & thorough information put your client at ease as they may feel uncomfortable about revealing sensitive information to you explaining your format helps clients accept & understand the purpose of the interview

Effective interviewing as a professional nurse, you will spend about half of your time obtaining information from clients & colleagues excellent communication as well as interviewing skills are fundamental, yet require years of practice

Why, what, how why do you need the information? how will the information I am seeking direct me in helping my client? how will you phrase your questions?

Who to Ask? if the client is able to speak, ask him/her family perspectives may also be important written consent may be required to question concurrent/previous healthcare providers be courteous and respectful never forget client confidentiality

INTERVIEWING TECHNIQUES in general, use open-ended questions however, to obtain specific information, closed-ended questions are preferable validate information clarify responses use reflective questions/comments & paraphrasing

Role of the nurse ◦ Accepting, respectful, nonjudgmental attitude Role of the patient ◦ Active participant

Factors Influencing the Interview Approach Environment Confidentiality Time, length, duration Biases and preconceptions

Stages of the Interview Process Stage I — Orientation Stage II — working Stage III — termination

Orientation Phase “getting to know you” phase setting the tone making introductions establishing roles reaching agreement on goals developing trust

Once orientation phase completed & trust level fairly comfortable, time for Identification of the problem or problems that are shared by the client.

Working phase “problem solving” phase attending to client’s needs Nurse in role of teacher/counselor encouraging active participation by client gathering further data assisting client in decision making facilitating change Evaluate problems & goals

reviewing & summarizing goals met and progress made acknowledge feelings of loss reassuring clients with issues such as, “How will this problem/disease affect my life ?”

Avoid Arguing Minimizing Challenging Giving false reassurance Interpreting or speculating on the dynamics of the client’s problems “Selling” client on accepting treatment Probing sensitive areas Participating in criticism of any staff member Joining any attacks led by the client

Communication skills in patient interview Communication is “an interaction between 2 or more persons that involves the exchange of information between a sender and a receiver” It involves the expression of emotions, ideas, and thoughts through verbal and non-verbal signals.

Factors Affecting Communication Active listening Nonverbal communication Distance Personal space

Communication is a two-way process Message SenderReceiver

Essential Skills Active listening Clarifying Comforting Focusing Informing Paraphrasing Reflecting Restating Summarizing Suggesting Therapeutic silence Open-ended statements and questions

Effective Interviewing Techniques Verbal techniques ◦ Open-ended questions ◦ Closed questions ◦ Facilitation ◦ Silence Nonverbal techniques ◦ Touch ◦ Attentiveness

Barriers to Effective Communication Offering your opinion Giving false reassurance Defensiveness Showing approval or disapproval Stereotyping

Therapeutic Versus Nontherapeutic Communication THERAPEUTIC - Facilitates transformation of working nurse-patient relationship - Relationship allows for adequate & accurate data collection & assessment - Performed with & not for patient

Therapeutic Versus Nontherapeutic Communication NONTHERAPEUTIC - Hinders relationship formation - Prevents patient from becoming mutual partner & relegates him/her to passive recipient of care