The goal of patient interviews is to develop a therapeutic relationship and make a diagnosis. A therapeutic relationship comprises the healthcare provider and patient feeling comfortable with each other. The patient comes to the interview to seek relief from an illness, while the healthcare provider understands the patient's problems to provide a remedy. They trust that the care provider will listen to the issues and offer them comfort and confidence (Dang et al., 2017). Diagnosis involves an evaluation of the patient's signs and symptoms. The care practitioner obtains information on the patient's signs and symptoms by asking specific questions. At the end of the interview, the practitioner comes up with a differential diagnosis to determine appropriate treatment options.
The healthcare provider needs to follow specific interview guidelines. For instance, the interview setting ought to be comfortable, free from disturbances, and discreet. Besides, the questions should be open-ended, focused, and specific to allow patients to express themselves. Also, the care provider needs to ask the patient for clarification and make further explanations. Additionally, the healthcare practitioner ought to be emphatic and pay attention to the patient's emotional responses.
Healthcare providers are likely to make mistakes when providing care for students. I remember an incident where I used an improper technique to measure a patient's blood pressure. The patient was a teenager who had fainted at the school playground. I put the sphygmomanometer on the patient's arm without removing his sweater. Due to this mistake, the patient's blood pressure measurements increased by 40 points. The overall high blood pressure points seemed odd since there was no history of blood pressure or anxiety. While retracing my steps, I identified that the patient had his sweater on, which explained the elevated pressure. The incident made me learn that staying calm during emergencies is significant.
Medical history refers to a report that has the medical recollections and concerns of a patient. The critical components of a patient history are chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). Chief complaint or concern refers to the patient's primary reason for a visit, such as persistent headaches. HPI is the patient's comprehensive details of the chief complaint and the symptom progression (Mathioudakis et al.,2016). For instance, constant headaches for one week, causing dizziness. The ROS involves a list of questions that seek to obtain further information on the patient's additional symptoms or previous and current problems. Lastly, the PFSH comprises information on the patient's previous illnesses, medications, and incidence among family members.
Healthcare providers should be culturally competent when providing care. Doing so will prevent misunderstandings and barriers from caring. I have experienced a few obstacles in the process of patient assessment. For instance, one of my patients, a pregnant Muslim woman, did not seem pleased with being assessed by a male practitioner. She seemed very uncomfortable and could not answer my questions. I could not conduct an ultrasound since she was unwilling to remove her clothes. To ensure she received adequate care, I requested a female colleague from another department to do the assessment. I later discovered that female Muslim patients prefer dealing with female healthcare providers and do not like to expose their bodies.
Dang, B. N., Westbrook, R. A., Njue, S. M., & Giordano, T. P. (2017). Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Medical Education, 17(1), 32.
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe, 12(4), 369-373.
A patient interview can be defined as obtaining detailed information about a patient to give out the necessary information to a Medical Centre and the patient's history to experts in pharmacists (Pariser, 2016). A patient interview's major objectives are to determine whether the patient experiences problems after using therapeutic drugs, facilitate diagnosis of different diseases, and promote the therapeutic relationship between the patient and the physician.
One of the components of patient history is the history of present illness (HPI). It explains the current illness and how it developed with time. HPI is formatted and recorded about the location, symptoms, time, and severity of the illness. HPI can be classified as brief if it contains less than four elements or extended when the elements are more than four (Karp, 2019).
The second component of patient history is the chief complaint (CC): CC is the specific reason why the patient has visited the health care unit (Karp, 2019). CC is normally recorded, as stated by the client. In all the encounters, CC must be present, and it normally shows the specific condition or complaint from the patient. For instance, a patient might be complaining of breathing problems.
Review of systems (ROS). ROS refers to questions normally used to explain extra information when more symptoms, signs, or complications are observed by the patient on previous or current occasions. For example, complications experienced in body organs or systems. If ROS comments on one system are described as brief, if it contains two to nine systems are classified as expanded, and lastly, if it explains more than ten systems is categorized as complete (Karp,2019). In ROS, information can be recorded by anyone, including the patient. The physician can do a complete ROS documentation in two different ways. The first way is by documenting each system individually, for example, abdominal pain (kidneys), while the second way is by stating the positive findings and the negative ones concerning the CC.
The force of blood that pushes through the blood vessel at a particular time is called blood pressure (“American Heart Association”, 2017). The primary point for measuring blood pressure is at the branchial artery. On one occasion when newly graduated, I had not prepared myself for carrying out the operation, and the results were not quite good. I used the finger cuff method, which is least efficient though it is normally used on most occasions. I made a mistake by placing my finger on the wrong vessel and ultimately placing the blood pressure cuff the wrong way. From this incident, I learned that before carrying out any test or sense of awareness is very important, and being ready to use the right method is significant.
My interview was with a patient suffering from osteoarthritis, a disease that causes pain in joints, especially in elderly people. My goal for this interview was hearing out the patient and listen carefully to all his concerns. Having different cultures with the patient there resulted in a barrier, especially in communication. Gathering the information had turned to be hard at the start, and this required the involvement of a family member to interpret the message for me.
Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data set. CIN: Computers, Informatics, Nursing, 37(5), 260-265.
American Heart Association. (2017). What is high blood pressure? South Carolina State Documents Depository.
Pariser, D., Schenkel, B., Carter, C., Farahi, K., Brown, T. M., Ellis, C. N., & Psoriasis Patient Interview Study Group. (2016). A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis. Journal of Dermatological Treatment, 27(1), 19-26.
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