Health History Interview

Social Conversation

vs

Aim for other’s health improvement

Express one’s interest or need.Responsible for oneself

Health History Interview

1. Establish trust & supportive relation

2. Gather information

3. Offer information

Most value skill of clinical care

Much more than just asking a question

ObjectiveObjective

Techniques promote trust & communication

Unfold the patient’s story in detailed form

Generate hypothesis about the nature of patient’s concernGenerate hypothesis about the nature of patient’s concern

Test hypothesis by asking more detailed informationTest hypothesis by asking more detailed information

Explore the patient’s belief and feelingsExplore the patient’s belief and feelings

If little can be done, discussing the patient’s experience can be RxIf little can be done, discussing the patient’s experience can be Rx

clin

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pt’s perspective

Rx

Health History Format

Structured framework for

patient’s information

Structured framework for

patient’s information

Focus clinician’s attention on

specific pieces of information

Focus clinician’s attention on

specific pieces of information

Interview Process

Generate the piece of

information is more fluid

Generate the piece of

information is more fluid

Require :

knowledge of information

ability to elicit accurate and detailed

information

interpersonal skill response pt’s

feeling

Require :

knowledge of information

ability to elicit accurate and detailed

information

interpersonal skill response pt’s

feelingusually clinician’s perspective Include patient’s perspective

Factors that influent health history

1. Patient’s need and concern

2. Clinician goal of encounter

3. Clinical setting (IPD, OPD, PCU, subspecialty)

Getting Ready: the approach to interview

Require planning:

Take time for self reflection

Reviewing the chart

Setting goal for the interview

Reviewing clinician behavior and appearance

Improving the environment

Taking note

clinician

information

patient

Take time for self reflection Take time for self reflection

Clinician’s challenge: Clinician’s challenge:

being consistency open and respectful toward

Individual differences.

is a continual part of professional development in clinical work

must look inward to clarify how our own expectation

and reaction (value, assumption, bias).

Reviewing clinician behavior and appearance Reviewing clinician behavior and appearance

Just you observe the patient, the pt. will be watching you.

Consciously or not, you sent message through words

and behavior.

Being sensitive to non-verbal message, should be calm and

unhurried, even time limited.

Must take pain, not to express negative feeling.

Try to consider the pt’s perspective, you want the pt. to trust you

Reviewing the chart Reviewing the chart

Goal Goal

gather information

develop ideas about what to explore

should not let the chart prevent you to develop new idea.

Setting goal for the interview Setting goal for the interview

Student → write up patient’s report

Clinician → make healthy balance between

provider centered goalprovider centered goal patient centered goalpatient centered goal

institute

health insurance

family

Taking note Taking note

do not let note taking distract you from pt.

jot down specific words, not in format

keep eye contact, put down the pen during sensitive feeling

when find uncomfortable, explore concern and explain,

you need accurate record

always keep eye on patient’s feeling

Improving the environment Improving the environment

sitting distance

making privacy and comfortable

Learning about the patient’s health

devote timedevote time

fully ready to listenfully ready to listen

elicit patient’s concernelicit patient’s concern

The process of interview

Greeting the patient and establish rapport

Inviting patient’s story

Establish the agenda for interview

Expand and clarify the patient’s story

Generate and testing diagnostic hypothesis (clinician perspective)

Create shared understanding of problems

Negotiating a plan

Planning to follow up and closing interview

Greeting the patient and establish rapportGreeting the patient and establish rapport

Physical setting shape the patient first impression

Greet the patient by name

Maintain confidentiality

Let the patient decide if third party needed

Attune the patient’s comfort

Arrange the seat in appropriate distance

Spend small talk to put the patient as ease

Inviting patient’s storyInviting patient’s story

Chief complaint : begin with open question

Listen without interrupt, give opportunity to response fully

Train yourself to follow the patient’s lead, listen actively,

use continuer… go on

Establish the agenda for interviewEstablish the agenda for interview

The clinician always approach with specific goal in mind,

the patient also has specific questions and concerns

Identify at the beginning, allow time effectively, make sure

you addressed all patient’s issues

If many problems…approach the most concerned one…list

others…all are important…will be addressed at next visit

Expand and clarify the patient’s storyExpand and clarify the patient’s story

Use understandable language (pt’s word)

Facilitate pt’s story by different type of questions

Move back and forth from open ended questions to direct

question to another open ended question

Established sequence and time course

Each symptom must be clarified: 7 attributesLocationCharacterSeverityTimingSettingRemitting/aggravatingAssociated symptoms

Generate and testing diagnostic hypothesis (clinician perspective)

Generate and testing diagnostic hypothesis (clinician perspective)

Specific detailed might differentiated one disease

from another

Built evidence for and against diagnostic possibility

Review systems for additional data

Create shared understanding of problemsCreate shared understanding of problems

“disease” vs. “illness”“disease” vs. “illness”

To understand the patient’s expectation & concern -

asking patient-centered questions in 6 domains:

the pt’s thought about illness

the pt’s feeling, fear

the pt’s expectation

effects to the pt’s life

prior experience

Rx response already tried

Negotiating a planNegotiating a plan

Help the patient create complete picture of problems

and form a basis for planning further evaluation.

Autonomy and voluntariness

Planning to follow up and closing interviewPlanning to follow up and closing interview

May find that ending if difficult, if pt. enjoys discussing

May close up with summary plan.. take medicine…get

blood test and make appointment for next visit.

If pt. brings new issue, simply reassure of your interest,

make plan to address this problem in future time

Facilitate the patient’s story

Active listening

Adaptive questioning

Non-verbal communication

Facilitation

Echoing

Empathic response

Validation

Reassurance

Summarization

Highlighting transition

Adaptive questioning Adaptive questioning

1. Direct questioning from general to specific

use open-ended question

2. Questioning to elicit graded response

3. Asking a series of questions at one time…

4. Offering multiple choice for answer

5. Clarifying what the patient means

Comprehensive Health History Format

Date and timing

Chief complaint (s) : pt’s words

Present illness : including bellowed relevant history

Past history: medical, surgical, Ob-Gyn, vaccination, screening for diseases

Family history: hereditary, contact diseases, cancer, cause of death,

Personal and social history: occupation/school, source of stress, economic,life style, belief, health and safety behavior – diet, exercise, comparative medicine,drugs, alcohol, smoking

Review of systems

Identifying data Reliability

Preparing the physical examination

Reflect on your approach to the patient

Decide on the scope of examination: comprehensive or focused

Choose the examination sequence: head to toe

Adjust the lighting and environment: adjust bed, tangential light

Promote patient comfortable:

Reflect on your approach to the patientReflect on your approach to the patient

Appear calm organize and competent

Avoid showing distaste, alarm, or negative reaction

Sharing the findings with patient

Make sure washing your hand in the presence of patient.

Promote patient comfortable:Promote patient comfortable:

Keep privacy, consider third party

Art of draping: visualize one area of the body at a time

Keep pt. informed when anticipate discomfort or embarrassment

Give instructions at each step

Be sensitive to the patient’s feeling, watching facial expression

When finished, tell the pt. general impression and what to expect next.

Rearrange the environment to the pt’s satisfaction