​The Interview

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Introduction:

As a medical professional, it is crucial to understand the significance of a medical interview and the documentation process. Adequate documentation is essential to provide a comprehensive health history, diagnose the present illness, and establish an effective therapeutic relationship with the patient. In this article, we will discuss the significance of documentation, the difference between subjective and objective data, and how to develop strong communication skills while conducting an interview.

1. What does it means to document accurately and appropriately?

Documentation is the process of collecting, recording, and managing patient data. Accurate and appropriate documentation ensures that the patient receives comprehensive care throughout their medical journey. It also helps to prevent miscommunication and mistakes in treatment plans. Proper documentation includes the patient’s personal details, health history, current diagnosis, and prescribed medications.

2. What are the documenting guidelines? When is it appropriate to use abbreviations?

Documentation guidelines vary depending on the organization, state, or country. However, some common documentation guidelines include writing legibly, using standardized abbreviations, using proper grammar, and spelling. It is appropriate to use abbreviations when they have a universally accepted meaning and help in saving time and space.

3. What is the difference between subjective and objective data?

Subjective data is the information provided by the patient regarding their symptoms, feelings, and experiences. Objective data is the healthcare provider’s observations, physical exam findings, diagnostic test results, and laboratory values. Objective data is essential to confirm or rule out the initial diagnosis based on the subjective data.

4. What does it mean to demonstrate clinical reasoning skills?

Clinical reasoning is the process of determining the diagnosis and treatment plan based on the patient’s subjective and objective data. Demonstrating clinical reasoning skills involves identifying the patient’s underlying medical condition and developing a comprehensive treatment plan.

5. How can you use clinical reasoning to plan the organization of a comprehensive exam?

Clinical reasoning plays a vital role in planning the organization of a comprehensive exam. The healthcare provider can use clinical reasoning to determine which tests and assessments are necessary for the patient’s diagnosis. They can also determine the order of the assessment, depending on the patient’s medical history and presenting symptoms.

6. How will you document variations of normal and abnormal assessment findings?

Documenting variations of normal and abnormal assessment findings requires attention to detail. Healthcare providers should document their findings as accurately as possible, including the location, size, and color of any abnormalities. They should also document variations from normal findings and compare them to previous results if available.

7. What factors influence appropriate tools and tests necessary for a comprehensive assessment?

Factors influencing appropriate tools and tests necessary for a comprehensive assessment include the patient’s presenting symptoms, medical history, age, gender, and social background. The healthcare provider should also consider the patient’s overall health status, preferences, and financial status before ordering any tests or assessments.

8. Reflect on personal strengths, limitations, beliefs, prejudices, and values. How will these impact your ability to collect a comprehensive health history?

Personal strengths, limitations, beliefs, prejudices, and values serve as an advantage and a hindrance while collecting a comprehensive health history. Personal beliefs and prejudices can affect a healthcare provider’s ability to remain objective while collecting patient information. On the other hand, personal strengths such as communication skills can help healthcare providers communicate effectively with the patient, leading to a successful diagnosis and treatment plan.

9. How can you develop strong communication skills?

Developing strong communication skills depends on understanding the patient’s language, culture, and social background. Healthcare providers should maintain proper eye contact, use active listening skills, and ask open-ended questions while collecting patient data. Healthcare providers should also avoid interrupting the patient while speaking and use plain language that the patient can easily understand.

10. What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?

The interviewing techniques suitable for eliciting subjective health information include open-ended questions, active listening skills, non-judgemental language, and establishing a comfortable rapport with the patient. Healthcare providers should also allow patients to guide the conversation and clarify any misunderstandings.

11. What relevant follow-up questions will you use to evaluate patient condition?

Relevant follow-up questions will depend on the patient’s presenting symptoms and the healthcare provider’s observations during the interview. For instance, if a patient reports chest pain, the healthcare provider may ask follow-up questions such as the duration of pain, the intensity, and the location of the pain.

12. How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?

Demonstrating empathy for patient perspectives, feelings, and sociocultural background involves validating the patient’s concerns and showing a willingness to understand their perspective. Healthcare providers should also respect the patient’s culture and beliefs and avoid imposing their own beliefs on the patient.

13. What opportunities will you take to educate the patient?

Opportunities to educate the patient include explaining the diagnosis and treatment plan, discussing preventive measures, and providing information on medication side effects. Healthcare providers should also provide educational resources such as support groups or websites where the patient can get additional information.