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History Taking and Interview PDF
History Taking and Interview PDF
and Interviewing
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OBJECTIVES
1. Describe the five steps of the nursing process and how it
applies to health assessment.
2. Describe an environment suitable for conducting an
interview and physical assessment.
3. Recognize personal perceptions and behaviors that facilitate
or hinder the interviewing process
4. Define effective interviewing techniques
5. Identify the components of the complete health history.
6. Describe how to assess the characteristics of a chief
complaint
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The Purposes of History Taking
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History Taking
Directs the focus of the physical exam
Often the basis for the differentail diagnosis
Keys:
Trust
Right questions
Interpreting the responses
Knowing what to do next
Care begins simultaneously
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The Interview The Interview
• Subjective data
• Results of a successful interview
• The interview as a contract between patient
and examiner
◦ Time and place
◦ Introduction and explanation
◦ Purpose
◦ Length
◦ Expectations
◦ Confidentiality
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The Interview
Process of Communication
• Sending
• Sending
• Receiving
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Process of Communication
• Internal factors
Liking others
Empathy
Ability to listen
• External factors
Ensure privacy
Refuse interruptions
Physical environment
Dress
Note-taking
Tape and video recording
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Establish Rapport
• Get organized
• Ensure privacy
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The Interview
Techniques of Communication-I
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The Interview
Techniques of Communication-II
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Listen!!!! but How ?
• Be an empathetic listener
• Use short supplementary phrases
• Listen for feelings as well as words
• Let the person know when you see body language that
conflicts with what they say
• Be patient if the patient has a memory block
• Avoid the impulse to interrupt
• Allow for pauses
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Observe, HOW?
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The Interview
Techniques of Communication-IV
• Responses—assisting
• Introducing the interview
the narrative
• Working phase
– Facilitation
– Open-ended questions
– Silence
– Closed or direct
– Reflection
questions
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary
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Techniques of Communication-V
• Introducing the interview • Responses—assisting
• Working phase the narrative
– Open-ended questions – Facilitation
– Closed or direct questions – Silence
– Reflection
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary
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How to ask Questions?
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The Interview
Techniques of Communication-VII
• Nonverbal skills
– Physical appearance
– Posture
– Gestures
– Facial expression
– Eye contact
– Voice
– Touch
• Closing the interview
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The Interview
Interviewing People With Special Needs
Hearing-impaired people
Acutely ill people
People under the influence of street drugs or alcohol
Personal questions
Sexually aggressive people
Crying
Anger
Threat of violence
Anxiety
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The Interview
Cross-Cultural Communication
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The Interview
Overcoming Communication Barriers
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Translation
Software /
Applications
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Observations
• Body language
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Observations • Body language
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PLEASE USE THE
PEDESTRİAN
UNDERPASS
It's not what you say, it's how you say it.
Observations
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How to terminate the interview
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Charting & Documentation
• If it isn’t written, then it wasn’t done
• Chart at the time it occurs – if possible
• Follow facility guidelines
• Is the information clear and logical?
• Is it true?
• Is it non - judgmental?
• Record all abnormals and normals
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Charting guidelines
• Be precise
• Stick to the facts
• Sign your name after each entry
• SOAP format, SOCRATES – focuses on specific
problems
• Prioritize the client problems
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