·Communication techniques used to obtain a patient's health history
Courtesy, Comfort, Connection, Confirmation
Courtesy Communication Technique
• Knock before entering a room.
• Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is all right to shake hands.
• Meet and...
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·Communication techniques used to obtain a patient's health history
Courtesy, Comfort, Connection, Confirmation
Courtesy Communication Technique
• Knock before entering a room.
• Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.)
It is all right to shake hands.
• Meet and acknowledge others in the room and establish their roles
and degree of participation.
• Learn their names.
• Ensure confidentiality.
• Be in the room, sitting, with no effort to reach too soon for the
doorknob.
• If taking notes, take notes sparingly; note key words as reminders
but do not let note-taking distract from your observing and listening.
• If typing in the electronic medical record, type briefly and
maintain eye contact with patient, if possible.
• Respect the need for modesty.
• Allow the patient time to be dressed and comfortably settled after
the examination. Follow-up discussion with the patient still "on the
table" is often discomfiting.
Comfort Communication Technique
• Ensure physical comfort for all, including yourself.
• Try to have a minimum of furniture separating you and the patient.
• Maintain privacy, using available curtains and shades.
• Ensure a comfortable room temperature or provide a blanket—a cold
room will make a patient want to cover up.
• Ensure good lighting.
• Ensure necessary quiet. Turn off the television set.
• Try not to overtire the patient. It is not always necessary to do
it all at one visit.
Confirmation Communication Technique
• Ask the patient to summarize the discussion. There should be clear
understanding and uncertainty should be eased.
• Allow the possibility of more discussion with another open-ended
question: "Anything else you want to bring up?"
• If there is a question that you cannot immediately answer, say so.
Be sure to follow up later if at all possible.
• If you seem to have made a mistake, make every effort to repair it.
, Candor is important for development of a trusting partnership. Most
patients respect it.
Connection Communication Technique
• Look at the patient; maintain good eye contact if cultural
practices allow.
• Watch your language. Avoid professional jargon. Do not patronize
with what you say.
• Do not dominate the discussion. Listen alertly. Let the patient
order priorities if several issues are raised.
• Do not accept a previous diagnosis as a chief concern. Do not too
readily follow a predetermined path.
• Find out whether the patient has turned from other healthcare
providers to come to you.
• Take the history and conduct the physical examination before you
look at previous studies or tests. Consider first what the patient
has to say.
• Avoid leading or direct questions at first. Open-ended questions
are better for starters. Let specifics evolve from these.
• Avoid being judgmental.
• Respect silence. Pauses can be productive.
• Be flexible. Rigidity limits the potential of an interview.
• Assess the patient's potential as a partner.
• Seek clues to problems from the patient's verbal behaviors and body
language (e.g., talking too fast or too little).
• Look for the hidden concerns underlying chief concerns.
• Never trivialize any finding or clue.
• Problems can have multiple causes. Do not leap to one cause too
quickly.
• Define any concern completely: Where? How severe? How long? In what
context? What soothes or aggravates the problem?
SOAP Notes
S Subjective data—the information, including the absence or presence
of pertinent symptoms, that the patient tells you
O Objective data—your direct observations from what you see, hear,
smell, and touch and from diagnostic test results
A Assessment—your interpretations and conclusions, your rationale,
the diagnostic possibilities, and present and anticipated problems
P Plan—diagnostic testing, therapeutic modalities, need for
consultants, and rationale for these decisions
Ethical Considerations
• Autonomy: The patient's need for self-determination. Autonomy
suggests that choices exist, and a patient may choose between
alternatives. Uncertainty exists when the patient is a child or is
cognitively impaired. Parents, guardians, family, or other
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