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SOAP note - Answer: SOAP note is both a process and a documentation format
The Partnership with the Patient - Answer: Getting to know your client:
Culture
Physical characteristics Influence on health and illness
,Beliefs and behaviors Family relationships Preparing to be an effective health care provider
The History and Interviewing process - Answer: The history and physical exam begin the diagnostic and
treatment process
The techniques you will learn are orderly but not rigid
To prevent misinterpretations and misperceptions, you must make every effort to view the patient's
perspective.
GOALS - Answer: Discover information leading to diagnosis and management
Provide information about diagnosis
Negotiate and share health care management
Counsel about disease prevention
Autonomy - Answer: Patient's self-determination
Beneficence - Answer: Do good for the patient
Nonmaleficence - Answer: Do no harm to the patient
Utilitarianism - Answer: Appropriate use of resources for the greater good
,Fairness and Justice - Answer: Equitable treatment of all
Deontological imperatives - Answer: Care delivered according to traditions and in cultural contexts
Factors that Enhance Communication - Answer: Establishing a positive patient relationship depends on
communication built on: Courtesy Comfort Connection Confirmation Confidentiality
Be Professional:
Attire & Response
Enhancing Patient Responses - Answer: Establish rapport and trust-Seek connection
Open‐Ended Question-Allows patient discretion about the extent of an answer
Direct Question-Seeks specific information
Leading Question
-May limit the information provided to what the patient thinks you want to know
If the patient does not understand what you are asking, remember to: - Answer: Facilitate: Encourage
your patient to say more
Reflect: Repeat what you have heard.
Clarify: Ask "What do you mean?"
, Empathize: Show understanding and acceptance.
Confront: Address disturbing patient behavior.
Interpret: Repeat what you have heard to confirm the patient's meaning.
Communication TensionsLimit barriers - Answer: curiosity about you
anxiety
silence
depression
crying
physical intimacy
emotional intimacy
anger
avoidance
financial considerations
Setting for the Interview - Answer: comfort
removal of physical barriers
good lighting
privacy
quiet
unobtrusive access to clock
Taking the history usually begins... - Answer: your relationship with the patient