Obtaining a Health History- Interviewing
What are the reasons we might interview a patient? Correct Answer--
Develop a rapport
-Information collection for clinical decision-making
-Legal record
-Documentation
-Evidence-Based Practice shows good interviewing skills are a measure
of quality of care
Objective Data Correct Answer-Anything that can be measured or
observed particularly using the 5 senses.
-Vision
-Hearing
-Touch
-Taste
-Smell
Examples: HR or BP, UOP, Bleeding
Subjective Data Correct Answer-Anything that is stated and cannot be
verified such as feelings or Pain.
-Pain
-Dizziness
-Anything reported by the patient
, Examples: "I fell down the stairs." Complaints of Pain
Closed-ended questions Correct Answer-Questions that can be answered
with a simple "yes" or "no"
•Use for specific information
•Calls for short one to two-word answers
•Elicits cold facts
Ex. Are you feeling better today?
open-ended questions Correct Answer-Questions that can NOT be
answered with a "yes" or "no"
•Use for narrative information
•Elicits feelings, opinions, ideas
•Use to begin the interview and to introduce a new section of questions
Ex. Explain to me what is happening with your_____________.
The interview process Correct Answer--Check personal issues and bias
at the door
-Provide privacy and non-distracting environment
-Introductions
-Name, Title, Permission
-Patient Identifiers
-Name, DOB, MRN, address, photo
-Patient may remain clothed