Medical Interviewing

• introduction/setting the stage

• purpose of the interview

• chief complaint

• collection of pertinent data (OLDCAAARTS)

• review/recap of data

• transition to physical exam

• revisit interview if needed

what is the basic order/format of medical interviewing?

open ended questions

broad, vague questions that allow patient to express ideas in their own words and should be utilized at the beginning of the interview

closed ended questions

requires short answers, usually yes or no

non-verbal communication

hand shakes, eye contact, respecting personal space, reading social cues, body language, speech patterns

patient-centered approach

(clinician-centered utilizes only closed-ended questions and tends to feel more like an interrogation)

which approach is superior during medical interviewing: patient-centered or clinician-centered?

3+

(this is why it is important to not focus on one symptom)

patients in outpatient primary care settings average how many concerns per visit?

open-ended; closed-ended

patient-centered approach aligns with ____ questions and clinician-centered approach aligns with ____ questions

• CC

• HPI

• PMHx

• surgical Hx

• social Hx

• family Hx

• ROS

• PE

• laboratory data

• DDx

• treatment plan

what are the contents of a complete medical interview/H&P?

a way to address the emotions of the patient — name, understand, respect, support

(“you say this knee pain makes you angry, I can understand why you feel this way, this has been a difficult time for you, I want to help you get to the bottom of this”)

what is NURS?

limited english proficiency

what does LEP mean?

cultural competence

the ability to effectively communicate and interact with people from cultures different from one’s own, especially through a knowledge and appreciation of cultural differences

implicit bias

unconscious favoritism toward or prejudice against people of a particular ethnicity, gender, or social group that influences one’s actions or perceptions

cultural humility

the willingness to learn from patients how they would like you to interact with them

gather information, establish rapport, function as a therapeutic outlet, determine DDx

what is the purpose of a medical interview?

sit down

what is one of the most important things you can do to establish rapport and make the patient feel heard?

complete history

a history most often recorded the first time you see the patient

problem/focused history

a history taken for acute problems

interim history

a history of chronicles of events since the last visit

addendum

an addition to a documented note to include information that was not available at the time of the original entry

late entry

documentation that supplies additional information that was omitted from the original entry or not documented in a timely manner

subjective — identifying data of pt, CC, HPI, symptoms, PMHx, medications, pertinent ROS

what is the S in a SOAP note?

objective — vitals, lab results, PE findings, observed behaviors

what is the O in a SOAP note?

assessment — clinical reasoning and Dx

what is the A in a SOAP note?

plan — treatment, next steps, medications, referrals

what is the P in a SOAP note?

HPI

a chronological description of the patient’s current illness from first sign or symptom of the previous encounter; starts with an introductory sentence and is written as a paragraph; uses OLDCAAARTS

name, age, sex, and other information relevant to CC (PMHx, social/demographic information)

what is included in the HPI topic sentence?

• onset

• location

• duration

• characteristics

• aggravating

• alleviating

• associated symptoms

• radiation

• timing

• severity

what is OLDCAAARTS?

pertinent positives

information that reinforces your most likely diagnosis and can rule in a disease

pertinent negatives

information that can rule out certain conditions or move them down the DDx list

rule out

do you want to rule in or rule out first when making a diagnosis?