Some patients may want only a blood pressure check or routine examination, rithout having a specific complaint or problem. Others may say they just want physical examination but feel uncomfortable bringing up an underlying con-ern. In all these situations, it is still important to start with the patient's story. lelpful open-ended questions are "Was there a specific health concern that ^prompted you to schedule this appointment?" and "What made you decide to come in for health care now?"
It is important to train yourself to follow the patient's leads. Good interviewing techniques include using verbal and nonverbal cues that prompt patients to recount their stories spontaneously. If you intervene too early and ask specific questions prematurely, you risk trampling on the very information you are seeking. Your role, however, is far from passive. You should listen actively and make use of continuers, especially at the outset. Examples include nodding your head and using phrases such as "uh huh," "go on," and "I see." Additional facilitative techniques (p._) help keep you from missing any of the patient's concerns.
Establishing the Agenda for the Interview. The clinician often approaches the interview with specific goals in mind. The patient also has specific questions and concerns. It is important to identify all these issues at the beginning of the encounter. Doing so allows you to use the time available effectively and to make sure that you address all the patient's issues. As a student, you may have enough time to cover the breadth of both your concerns and the patient's in one visit. For a clinician, however, time management is almost always an issue. As a clinician, you may need to focus the interview by asking the patient which problem is most pressing. For example, "You have told me about several different problems that are important for us to discuss. I also wanted to review your blood pressure medication. We need to decide which problems to address today. Can you tell me which one you are most concerned about?" Then you can proceed with questions such as, "Tell me about that problem." Once you have agreed upon a manageable list, stating that the other problems are also important and will be addressed during a future visit gives the patient confidence in your ongoing collaboration.
Expanding and Clarifying the Health History (the Patient's Perspective). You can then guide the patient into elaborating areas of the health history that seem most significant. For the clinician, each symptom has attributes that must be clarified, including context, associations, and chronology, especially for complaints of pain. For all symptoms, it is critical to fully understand their essential characteristics. Always pursue the following elements.
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