10/16/24, 12:08 Exam 1 Physical Assessment 3,4,5,6,7,8,9,10,12
PM & 32
CHAPTER 3 – The Interview
Communication – Exchange of information; based on behavior
- Internal factors: Specific to examiner
o MAIN FOUR: Liking others, expressing empathy, ability to listen,
and self-awareness
- External factors: Relate to physical setting
o Ensure privacy, prevent interruptions, create conducive
environment, arrange equal-status seating, wear appropriate attire,
document responses
Interview – Three phases
1. Introduction: introduce yourself and state your role
2. Working phase: gather data. Start with open ended questions, then
use direct/closed questions.
3. Closing: Signal interview is ending, summarize what you
learned. Verbal responses
- Patients frame of reference: Facilitation, silence, reflection, empathy,
and clarification
- Own frame of reference: Confrontation, interpretation,
explanation, summary
Ten traps of interviewing to avoid:
• Providing false assurance or reassurance
• Unwanted advice
• Using authority
• Using avoidance language
• Distancing
• Professional jargon
• Biased questions
• Talking too much
• Interrupting
Limited English proficiency or hearing-impaired persons
about:bl 1/
, 10/16/24, 12:08 Exam 1 Physical Assessment 3,4,5,6,7,8,9,10,12
PM & 32
- Use interpreter or bilingual team member, avoid using family member.
When communicating with other professionals use SBAR
- Situation, Background, Assessment, Recommendation
CHAPTER 4 – Complete Health History
Purpose of complete health history is to collect SUBJECTIVE DATA
Gather data in eight categories:
- Biographic data: name, DOB, primary language, communication needs
- Source of HX: usually patient, may be family member
- Reason for seeking care
- Present health/history of present illness: general state of health
o Symptom analysis when reported: PQRST (provocative or
palliative (what provokes or alleviates pain), quality or quantity
(sharp, dull, stabbing, burning, etc.), region or radiation, severity
scale, timing)
- Past health events: childhood illness, chronic illness, accidents or injuries,
surgeries, OB history, immunizations, allergies, last exam date,
medications.
- Family history: also includes religion or spirituality
- Review of Systems: head-to-toe
- Functional assessment: activities of daily living, self-care ability, self-
esteem, substance abuse, partner violence, occupational health
Adjustments to make for a child's health history:
- Prenatal and perinatal history
- Developmental overview
- Nutritional history
Adjustment to make for assessing adolescent health history:
- HEEADSSS: home environment, education, employment, eating,
(peer- related) activities, drugs, sexuality, suicide/depression, safety
about:bl 2/
PM & 32
CHAPTER 3 – The Interview
Communication – Exchange of information; based on behavior
- Internal factors: Specific to examiner
o MAIN FOUR: Liking others, expressing empathy, ability to listen,
and self-awareness
- External factors: Relate to physical setting
o Ensure privacy, prevent interruptions, create conducive
environment, arrange equal-status seating, wear appropriate attire,
document responses
Interview – Three phases
1. Introduction: introduce yourself and state your role
2. Working phase: gather data. Start with open ended questions, then
use direct/closed questions.
3. Closing: Signal interview is ending, summarize what you
learned. Verbal responses
- Patients frame of reference: Facilitation, silence, reflection, empathy,
and clarification
- Own frame of reference: Confrontation, interpretation,
explanation, summary
Ten traps of interviewing to avoid:
• Providing false assurance or reassurance
• Unwanted advice
• Using authority
• Using avoidance language
• Distancing
• Professional jargon
• Biased questions
• Talking too much
• Interrupting
Limited English proficiency or hearing-impaired persons
about:bl 1/
, 10/16/24, 12:08 Exam 1 Physical Assessment 3,4,5,6,7,8,9,10,12
PM & 32
- Use interpreter or bilingual team member, avoid using family member.
When communicating with other professionals use SBAR
- Situation, Background, Assessment, Recommendation
CHAPTER 4 – Complete Health History
Purpose of complete health history is to collect SUBJECTIVE DATA
Gather data in eight categories:
- Biographic data: name, DOB, primary language, communication needs
- Source of HX: usually patient, may be family member
- Reason for seeking care
- Present health/history of present illness: general state of health
o Symptom analysis when reported: PQRST (provocative or
palliative (what provokes or alleviates pain), quality or quantity
(sharp, dull, stabbing, burning, etc.), region or radiation, severity
scale, timing)
- Past health events: childhood illness, chronic illness, accidents or injuries,
surgeries, OB history, immunizations, allergies, last exam date,
medications.
- Family history: also includes religion or spirituality
- Review of Systems: head-to-toe
- Functional assessment: activities of daily living, self-care ability, self-
esteem, substance abuse, partner violence, occupational health
Adjustments to make for a child's health history:
- Prenatal and perinatal history
- Developmental overview
- Nutritional history
Adjustment to make for assessing adolescent health history:
- HEEADSSS: home environment, education, employment, eating,
(peer- related) activities, drugs, sexuality, suicide/depression, safety
about:bl 2/
