What is essential for a successful assessment? Gaining the patients trust
Stages of the assessment interview Introduction Phase: Client/patient needs to understand the purpose of the interview.
Stage 2: Working Phase: Information gathering
Stage 3: Closing Phase: Summarize information in a positive and hopeful manner.
Ways to enhance patients responses Open-ended questions. Ex: What are your feelings about this? Direct questions. Ex:
Where does it hurt?
The health history provides subjective data based on: The perceptions of the client/patient,The perceptions of the interviewer,Signs
perceived by assessor through physical exam are objective data, Actual findings
through physical examination of an assessment, use of sight, tough, smell, hearing, A
combination of subjective and objective information result in the initial information of
the assessment.
interviewing techniques Open-Ended Questions - Require explanation
Closed Questions - Yes or no response
Directive questions - Using scenarios as an example
Use of Silence- Allowing the person time to respond
Facilitation - Presenting choices
Use of examples - Sense of inclusion
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How do the following interviewing techniques work: Restatement
Restatement, Reflection, Clarification, Summary, Ensures understanding
Confrontation Reflection
Allows emotional connection
Clarification
Reviews determination
Summary
Agree to decision
Consent to assessment findings
Confrontation
Avoid, use only with unresponsive
Assertiveness encourages participation
Examples of non-verbal communication include: Posture, physical appearance, tone of voice, facial expression, eye contact.
Types of Histories Complete history: become familiar with the client
Inventory history: touches major points. Get a " feel" for the situation
Problem/focused history: acute situation life-threatening, only need of the moment
information necessary.
Interim history: account of events since last meeting with patient. Additional to last
record.
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