Patient Interview
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Transcript Patient Interview
Patient Interview
Chief complaint- subjective statement
regarding most significant symptoms or
signs of illness
Description of general health
Description of lifestyle
Changes in status since last visit
All info is considered confidential!!
Components
The interview will become part of a legal
document- follow the 6 c’s
Client’s words in quotation mark’s
Clarity
Completeness
Concise
Chronological
Confidentiality
6 C’s
Private area without interruptions
Develop plan before interview, look up pt.
hx, chronic problems, meds etc…
Use broad knowledge base- look up
diseases, drugs tests, etc.. That you don’t
know
Tips for successful interview
Open-ended
Hypothetical questions
Mirroring response
Focusing on pt.
Encouraging pt. to take lead
Encouraging pt. to evaluate his/her
situation
Effective questioning
Closed-ended questions
Leading questions
Challenging
Probing
Agreeing or disagreeing
Ineffective questioning
Methods include: inspection, palpation,
percussion, auscultation, mensuration,
manipulation
Examination of pt.
Neurological: LOC- level of consciousness
and orientation to person, place and time.
Motor ability- ambulation. Senses,
speech, hearing, vision
Cardiovascular/pulmonary:
characteristics of peripheral(arm/leg)
pulses. Characteristics of respirations:
shallow, deep, regular, dyspnea, SOB.
Breath sounds- crackles/rhonchi, rales,
wheezes, diminished, labored. Coughproductive or nonproductive
Components of general physical
exam
Integumentary: wounds, scars,
ecchymosis, contracture, rash,
lacerations, decubitus ulcers. Color,
temp., surgical incisions, stitches, staples
Musculoskeletal: contractures,
amputation, deformity, atrophy, ROM,
ambulation, fractures, dislocations
Gastrointestinal: Abdomen, bowel
sounds, nutrition, NG tubes, special diets,
I&O
Exam cont.
GYN/Reproductive: Date of LMP, breast
self-exam, testicular exam, problems
Elimination: Stool- constipation, diarrhea,
date of last bowel movement. Urinevoiding, incontinent, dysuria, nocturia,
foley catheter, external catheter
Exam cont.
Psychosocial: affect, mood, anxious,
angry, conversant, defensive, noncooperative, combative. Living
environment: alone, with spouse, nursing
home, etc. Vocation/avocation: jobs,
hobbies, interests
Exam cont.
Symptoms: Objective and subjective
Diagnostic tests and their results
Plan of action: meds, therapies,
surgeries, diet, activity level
Documentation of result of tx
Modification of plan
Pt. education
Components of tx plan
S- subjective symptoms (pt. says)
O- objective sx (can be seen or
measured)
A-assessment, dx
P- plan (tx plan)
I- Implementation (putting plan in action)
E- evaluation (results of plan)
R-revision (change plan based on
evaluation)
SOAPIER
Diabetes: inability of pancreas to produce
enough insulin resulting in lack of sugar
available for cell metabolism.
Symptoms: polyuria, polydipsia,
polyphagia, sudden weight loss
Diagnostic tests: Fasting blood sugar,
glucose tolerance test
Sample treatment plan
Plan of action: insulin SQ, ADA diet,
moderate exercise
Pt. education: use of glucometer, insulin
injections, symptoms and treatment of
insulin shock, care of infections, care of
feet (prone to develop foot ulcers that can
result in amputation)
Treatment plan cont.