Pre-brief
Obtaining an accurate history is
the critical first step in determining the etiology of a patient's problem. A
large percentage of the time, you will actually be able to make a diagnosis
based on the history alone. The value of the history, of course, will depend on
your ability to elicit relevant information. Your sense of what constitutes
important data will grow exponentially as you practice your interviewing skills
and through increased exposure to patients and illness. However, you are
already in possession of the tools that will enable you to obtain a good
history. Specifically, you must listen and ask appropriate questions to define
the nature of a particular problem. In fact, seasoned clinicians occasionally
lose sight of this important point, placing more reliance on the use of
diagnostic testing rather than taking the time to listen to their patients.
Interviewing patients is an art and should remain an essential skill for
successful practice.
In this activity, you will interview Tina Jones to collect
data to assess Ms. Jones' condition. You will also have the opportunity to
educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing
evidence from the data you collected; prioritize the identified problems to
differentiate immediate from non-immediate care; plan how to best address the
most important concern with further assessment, interventions, and patient
education; and compare your documentation to model documentation.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview. Reason for visit: Patient presents for an initial primary care visit today complaining of a right foot wound.
Results Included:
- Overview
- Transcript
- Subjective Data Collection
- Objective Data Collection
- Education and Empathy
- Documentation / Electronic Health Record
- Information Processing
- Certificate of Completion
Instituition / Term | |
Term | Summer Session |
Institution | Chamberlain |
Contributor | Peterson |