Chapter 3: Interviewing and the Health History

Patient-centered Interviewing
 Skilled interviewing is both patient-centered and clinician-centered
o Evidence suggest that the patient is the best serv ed by
integrating these interviewing styles, leading to a more complete
picture pf the pt’s illness and allowing clinicians to more fully
convey the caring attributes of respect, empathy, humility and
sensitivity.
 Primary goals of the pt interview are to listen and to improve the well-
being of the pt through a trusting and supportive relationship.
 High quality pt-clinician communication has also been shown to improve
pt outcomes, decrease symptoms, improve functional status, reduce
litigation, and decrease errors.
 Following the patient’s lead to understand their thoughts, ideas,
concerns, and requests, without adding additional information from the
clinician’s perspective
 Encourages patients to express what is most important to them
 Patient-centered interviewing along with establishing patient rapport and
trust is the foundation for a therapeutic alliance
Interview Process
 Different but complementary to the health history format
o Health History format: is a structured framework for organizing pt
information in a written or verbal form. This format focuses your
attention on the specific kinds of information you need to obtain,
facilitates clinical reasoning, and standardizes communication to
other health care providers involved in the patient’s care.
 Limit “yes-no” questions to the Review of symptoms.
 Generates the patient’s story in a fluid manner, requires empathy
(empathic responses, validation), effective communication (active
listening, guided questioning, summarization), and the relational skills
(nonverbal affirmation, reassurance, partnering) to respond to patient
cues, feelings, and concerns
Skilled Interviewing Techniques
 Active Listening
o Paying attention to what the patient is saying, being aware of the
patient’s emotional state, and using verbal and nonverbal skills to
encourage the speaker to expand on concerns
o It takes practice; it is easy to begin thinking about next questions
or possible diagnoses
o Patient’s Perspective on Illness
 What the patient thinks may be going on
 The greatest concern or problem
 Expectations for the visit
 Empathetic Responses
o Vital to building patient rapport
o Empathy is the capacity of the clinician to identify with the patient
and feel the patient’s pain as their own
o You must recognize the patient’s feelings and then address their
meaning
 “How do you feel about that”
o Responses must convey that you feel what the patient is feeling
and wish to incorporate them into the visit
 “It sounds like it has been hard for you”
o Nonverbal
 Placing your hand on the patient’s hand or arm, offering
tissues
 Guided Questioning
o Methods to gain more information from a patient without
interfering with the flow of their story
o The goal of a patient-centered interview is to facilitate full
communication, in the patient’s own words, and without
interruption.
o Too many closed ended or yes-no questions can make the patient
feel more passive, which can shut down the flow of patient ideas
and lead to loss of detail.

o Types of Guided Questioning

 Moving from Open-Ended to Focused Questions
 Questioning should start broad and become more
specific
 Avoid leading questions (the desired response is
suggested)
 Questioning that Elicits a Graded Response
 Rather than a single answer
 Asking a Series of Questions, One at a Time
 Pause and make eye contact after each question
 Offering Multiple Choices for Answers
 Clarifying What the Patient Means
 Encouraging with Continuers
 Using posture, gestures, or words to encourage the
patient to say more
 Echoing
 Repeating the patient’s last words encourages the
patient to expand on details and feelings.
 Helps to reveal characteristics about the complaint
but also potential meaning to the patient
  Nonverbal Communication
o Both yours and the patient’s
o Allows you to read the patient and send messages of your own
o Eye contact, facial expressions, posture, head position,
interpersonal distance and placement of arms or legs
o Mirroring position and language to the patient’s, can help develop
rapport
 Validation
o Acknowledge the legitimacy of the patient’s emotions and/or
thoughts and demonstrate understanding
 Reassurance
o Identify and acknowledge the patient’s feelings to promote a
connection
o Be careful of early or inappropriate reassurance as it can be
counter-productive
 Partnering
o Verbalize your commitment to the therapeutic alliance
 Summarization
o Communicates that you have been listening
o Identifies what you do and don’t know
o Enables the patient to add information or correct errors
o Helps with information management
 Transitions
o Tells the patient when you are changing directions
o Informs them of your expectations and what they should do next
 Skilled Interviewing Techniques
o Empowering the Patient
 Patients are responsible for their own care
 Patients who are self-confident and understand your
recommendations are more likely to adopt your advice,
make lifestyle changes, or take medications as prescribed.
 Evoke the patient’s perspective
 Convey interest in the person, not just the problem
 Follow the patient’s lead
 Elicit and validate emotional content
 Share information with the patients, especially at
transition points during the visit
 Make your clinical reasoning transparent to the
patient
 Reveal the limits of your knowledge

Preparing for the Interview

 Reviewing the Medical Record
 o Gather information and plan the areas you need to explore
o Look at the problem list, medications, and allergies
o Do not let previous diagnoses deflect you from making your own
assessment based on new approaches or ideas
o ALWAYS perform your own review, do not rely on other providers
review
 Setting Goals for the Interview
o Assessing a new concern, to treatment follow-up, to completing
forms
o A clinician must balance provider-centered goals with patient-
centered goals
 Reviewing Clinical Behavior and Appearance
o Professionalism
o Personal appearance
 Adjusting the Environment
o Do what you can to make the patient comfortable
Sequence of the Interview
 Greeting the Patient and Establishing Rapport
o Greet with formal name, but ask if they prefer another name,
introduce yourself, and shake hands
 Repeat this part until you are confident that the patient
knows who you are
o Acknowledge other people in the room (names, relationships,
confidentiality)
o Patient comfort (adjust position, put away belongings, say
goodbye to visitors)
o Arrange yourself in the space (appropriate distance, at eye level,
move any barriers)
o Small talk
o Note taking
 Establishing the Agenda
o Begin with open-ended questions that allow for full freedom of
response
o First problem may not be the most important
o Identifying all concerns can help negotiate the most pressing ones
and ones that can be postponed
o “Is there anything else?”, “Have we got everything?”
o They may give you multiple items; "what is the most important
thing to you today?"
o Prioritize the list
 Inviting the Patient’s Story
o Investigate the patient’s most concerning issue
 “Tell me more about…..”
 o Using an open-ended approach and guided questioning
encourage the patient to tell their story
o Intervening too early with specific questions and interruptions will
decrease the likelihood of continued sharing
 Exploring the Patient’s Perspective
o Feelings – patient’s fears or concerns about the problem; “What
concerns you most about the pain?”
o Ideas – about the cause of the problem; “What do you think
caused this pain?”
o Function and lifestyle effects – “What can’t you do now that you
could before?”
o Expectations – of the disease, healthcare, or clinician; “I am glad
that the worst pain is gone, so how can I help you now?”
 Identifying and Responding to the Patient’s Emotional Cues
o Patients may withhold their true concerns in up to 75% of acute
care visits but may offer clues to these concerns
o “How has this affected you?”, “How did that make you feel?”
o Respond immediately when you observe an emotional cue
 Naming – “That sounds like a scary experience”
 Understanding – “It’s understandable that you feel that
way”
 Respecting – “You have handled the situation well”
 Expanding and Clarifying the Patient’s Story
o Guiding the patient to expand on
the items of the health history that
seem the most important
o SACRED 7
o OLD CARTS: Onset, Location,
Duration, Character,
Aggravating/Alleviating Factors,
Radiation, Timing, Severity
o OPQRST: Onset,
Palliating/Provoking Factors,
Quality, Radiation, Site, Timing
o LOCATES: Location and Radiation, Other Associated Symptoms,
Character, Aggravating/Alleviating Factors, Timing, Environment,
Setting
o Use the patient’s words and refrain from medical jargon
o Vary the types of questions and interviewing techniques used to
fill in the missing information
o An interview moves back and forth from open-ended questions to
increasingly focused questions and then on to another open-
ended question
 Generating and Testing Diagnostic Hypotheses
o Identifying the attributes of each symptom and pursuing details
are fundamental to recognizing patterns of a disease and to
generating differential diagnoses.

Open-ended questions to hear the

story in the patient’s own words
Each symptom has its own triangle, which
becomes a paragraph in the History of
More specific questions about the Present Illness in the medical note
symptoms; OLDCARTS

Pertinent positives and negatives

from ROS

 Sharing the Treatment Plan

o Teach the patient about the disease
o Educate them on the “why” of treatment
 A treatment may not make them feel better but may
decrease the risk of complications
o Identify barriers to the proposed treatment plan
o Determine the feasibility of the proposed treatment plan
o Each partner has responsibilities
o Let the patient know what YOU are going to do to help them
 Closing the Interview
o Check that the patient understands the treatment plan
o Allow time for final questions
o Review further evaluation, treatments, and follow-ups
 “So, you will take the medication as we discussed, get the
blood test before you leave today, and make a follow-up
appointment for 4 weeks. Do you have any questions
about that plan?”