Shadow Health Conversation Notes (conversation Lab) Already Graded A

Shadow Health Conversation Notes (conversation Lab) Already Graded A A proper greeting: 1) uses a friendly tone 2) addresses both yourself and the patient by name 3) States your reason for being there The narrowing and broadening of scope in a health history interview occurs in the contexts of: an organized progression through topics related to patient health How to structure a health interview Greeting and identifying data Chief Complaints History of Present Illness (HPI) Family History Personal and Social History Review of Systems Greeting and Identifying Data Greet patient and confirm patients name, age, and gender Chief Complaint(s) Identify symptoms or concerns causing patient to seek care History of Present Illness (HPI) Assess symptoms and patient's thoughts and feelings about illness Medical History Determine allergies, presence and dates of childhood and adult illnesses, chronic health problems, immunization history, and past hospitalizations Family History Determine age and health, or age and cause of death, of parents, sibling, and grandparents, noting the presence of specific illnesses in family (e.g. hypertension, addiction, type II diabetes). Personal and Social History Evaluate education level, family and household dynamics, spiritual practices, personal interests, sleep habits, and lifestyle (e.g. tobacco, alcohol and illicit drug use, sexual history, exercise, and nutrition Review of Systems Assess the presence or absence of common symptoms related to each major body system. To Shape patient interviews Move from open questions to closed questions (shaped like a cone) Open questions "cast a wide net" - allow patients to communicate more generally, and allow them to emphasize their own concerns and priorities Open question examples: How did you injure your elbow? What are your stomachaches like? What prevented you from refilling your prescription? How have you been managing your blood pressure Key Open Question Words "Describe", "Tell me about", "How", "Why" Open Question tips - Ask the patient to elaborate or describe - Convey empathy and avoid judgement - Avoid unnecessary use of medical terminology or jargon - Use concise language to convey a clear meaning. Closed Questions "zoom in" on particulars and refine their understanding of an aspect of patient health Closed Question examples - Has your pain gotten worse? - Are your headaches focused on one side of your head? - Has the medication helped with your heartburn? - When did you start feeling fatigued? Key Closed Question words: "How many", "How Often", "Can you, do you, will you, are you", "is it, has it, have you, etc", "Which", "Who" Open or closed questions establish therapeutic rapport? Closed. Good for: - Sexual History - Substance use - Social or domestic problems - Trauma - Physical symptoms that the patient finds embarrasing for Conversational Flow: Move between open and closed questions.