Patient-Centered Case Management Assessment & Patient Interview Techniques Rose M. Turner, RN, BSN, ACM Thursday, January 8th, 2015 The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. �����\4 medications stored in the refrigerator), they use on occasion only or had not perceived as a medication. � �E+~ :ǫ��ܣ����l��$��#F/'��-�Բ�D��v:�Y kق㧻hn��9MǼ>ƭ�� ��,�%>dI��W{�W����q � Previous levels of lipids if ever checked or known. It is useful to confirm the gestational age, gravidity and parityearly on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely. Guide the interview responses by treating each medication separately, obtaining all information before moving onto the next medication. OF THE PSYCHIATRIC PATIENT 7.1 PSYCHIATRIC INTERVIEW, HISTORY, AND MENTAL STATUS EXAMINATION MYRL R. S. MANLEY, M.D. anamnesis / medical history Senior Lecturer Gemma Hurley uses a mock patient to take you through the principles of obtaining a clinical history for www.NurseLedClinics.com. Goals The goal of medication history interview is to obtain information on aspects of drug use that may assist in over all care of patient . A systematic review including over 4500 patients from 12 clinical settings (primary care offices, n = 2; specialty clinics, n = 6; and emergency departments, n = 4) showed that dizziness was due to peripheral vestibular or psychiatric causes in roughly 60% of cases. 53, June 1996, pages 1306-14. Although the three parts of the interview can be considered separately, they often weave together, e.g., mental status observations can be made from the moment the clinician meets the patient. The interviewer then attempts to gain a broader perspective on the patient’s personality by reviewing significant life events—current and past—and the patient’s responses to them (see table Areas to Cover in the Initial Psychiatric Assessment). Nurses need sound interviewing skills to identify care priorities. Sources of data The patient, the patient, the patient Family members, caregivers, providers Physician offices, clinical labs, hospitals etc Hospital charts, nursing home records, MARS Other pharmacies The patient. 1. Mohd. Mi Was Developed First In 1983 PPT. Watch for updates on COVID-19 diagnosis and treatment. 5 In one classic study, researchers evaluated the relative importance of the medical history, the physical exam, and diagnostic studies. Taking a history from a patient is a skill necessary for examinations and afterwards as a practicing doctor, no matter which area you specialise in. Step 05 - Drug History (DH) Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. Although it has a broad differential diagnosis, dysuria usually results from infection or inflammation of the bladder and/or urethra. Because the patient is telling their story, patient histories are referred to as subjective data, whereas laboratory tests, medical imaging test results and the physical examination, are called objective data. Title: Patient Assessment and Clinical Interviewing 1 Patient Assessment and Clinical Interviewing 2 Common Communication Mistakes Health Care Practitioners Make. This record will aim to provide you with some helpful tips; your patients will teach you the rest. 2.Verify medication history taken by other staffs and provide additional information where appropriate. chief complaint) Could any of the patient's medications have contributed to this hospital admission? Often patient’s don’t mention over-the-counter medication and non-prescription medications so be careful! Introduction (WIIPP) Wash your hands; Introduce yourself: give your name and your job (e.g. Past medical history. A recent study from France observed a large discordance between patient and physician evaluations of drug adherence and drug importance,17 which may be due to a lack of patient-centred communication. 3 Common Mistakes Presentation Summary : Discuss History of Motivational Interviewing. The psychiatric history is the record of the patient's life; it allows a psychiatrist to understand who the patient is, where the patient has come from, and where the patient is likely to go in the future. Chapter 36 Interviewing the Patient Taking a History - Free download as Powerpoint Presentation (.ppt), PDF File (.pdf), Text File (.txt) or view presentation slides online. Dr. Louise Gooch, ward doctor) Identity: confirm you’re speaking to the correct patient (name and date of birth) Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Previous levels of lipids if ever checked or known. 2. The nature of the psychiatric interview is getting the patient’s narrative. Older adults may have challenges with exercising regularly and … If you wonder whether you could do a better job asking the right questions about a patient’s medication history at admission, consider these 12 as a great starting point. The daughter is not sure what to do. Gestational age, gravidity and parity would also usually be included at the beginning of any documentati… Medical Conditions + Medications. 1 The patient's age, sex, and sexual history can help the clinician quickly delineate the most likely causes of dysuria. Always check if the patient has any allergies – to medication or otherwise. If you continue browsing the site, you agree to the use of cookies on this website. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Patient Interviewing: Health and Medication History Susan L. Lakey, PharmD Pharmacy 440 March 28, 2006 "It is more important to know what sort of patient has the disease than to know what sort of disease has the patient." Mindfulness and reflection is a form of mentoring through modeling for the patient. The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Labyrinthitis has a similar presentation but also includes hearing loss. What is the dose? The medical interview remains the most common task performed by physicians. MEDICATION HISTORY INTERVIEW. The information collected can be utilized to : 1.Compare medication profile with the medication administration record and investigate the discrepancies . -��8�*=�xl��BkЉB�/���+�mĔ�B;�SFh�x��� This reduces confusion and facilitates accurate documentation. Chapter 36 Interviewing the Patient Taking a History - Free download as Powerpoint Presentation (.ppt), PDF File (.pdf), Text File (.txt) or view presentation slides online. Clinicians perform, on average, over 200,000 interviews during their career. From Lessons from medicine and nursing for pharmacist-patient communication, Am Jour of Health System Pharmacists, Vol. Includes Rx’s, Rx’s filled elsewhere, samples, pills borrowed from family/friends, OTC’s and herbals and the outcome of therapy Hospital profiles/ MARS are objective History just taken off computer is objective but incomplete. Patient has no significant PMH, no medications, does not smoke, drink alcohol or use any other drugs. Encourage patients or carers to bring all their medicines or a list of medicines to the assessment Promoting Wellness in Older Patients. Submitted By : We strongly encourage you to approach these three domains in an integrated fashion. Discuss History Of Motivational Interviewing. !M�|x The Health History and Interview The purpose of collecting an entailed health history is to paint a picture of how the patient views themselves, as well as how the nurse observes them. Step 10: Evaluate the medication history obtained against at least one additional source. H��VMO�@�G���]�e�mWȇ*�R+�RE=@�PW N� ��wv։턭�Xޝy��͇�G���̾�G7��h��8��*eZ���f���g�y!͙Q}�yTV��)�Q'B�߀g*Xf����.ܲye�Y�?�2M�_�DG�>Nd�3�AW�Q�|�ztZƉ�`{'�Vt�W��1L��c��1��s�wƄ�R��$�Rr��%��+,��& 354 0 obj <>/Filter/FlateDecode/ID[<9E23006016FA0E4980A2C53776AEE481>]/Index[333 59]/Info 332 0 R/Length 106/Prev 183236/Root 334 0 R/Size 392/Type/XRef/W[1 3 1]>>stream You should begin every oral presentation with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Because personality manifests itself in relationships, it is part of the relationship story. Note whether there have been any heart attacks, any history of angina and any cardiac procedures or operations (type and date of intervention and outcome). William Osler, 1849-1919. Another challenge was the lack of a method to measure patients’ self-management. Although these three areas may seem distinct from one another, in fact they are deeply intertwined. Empathic responses during a health history assessment interview can be both verbal (“I understand”) and nonverbal (such as offering a tissue if the patient is crying). 6. Ask if the patient is currently taking any prescribed medications or over-the-counter remedies: “Are you currently taking any prescribed medications or over-the-counter treatments?” If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Beyond being empathic, be sure to validate patients’ feelings to help reassure them that their emotions are natural and reasonable and their problems are understood and will be fully addressed. h�bbd```b``�5 ��D�}���H�Pɨ&��E���`�L*��tyj2�d�Ub���o@lc' ���fd`����qX����0 ^z� # ��� �p(�I���H A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).Asking about a patient’s ideas, concerns and expectations allow you to gain insight into how a patient currently perceives their situation, what they are worried about and what they are expecting from the consultation. Varies according to the patient’s memory, trust, and mood The one or more symptoms or concerns causing the patient to seek care Don’t assume that if a patient brought in a medicine that they are actually taking it. If you continue browsing the site, you agree to the use of cookies on this website. View Patient Interview and History.pptx from PHARMACY PHA 321 at Hampton University. Assistant Professor h�b```�����@��(������03�!����Y+!�iA��[� &�̞�qFS9��jGG#�p]@����| There is also a submenu for further study and revision designed for use with the exercises suggested in this pack. Clipping is a handy way to collect important slides you want to go back to later. 6 Physicians were asked to predict their diagnosis after taking just the history, and … Tips to interview an inpatient yDo your homework before going into the room to conduct your interview Read through admission notes to find out past medical history and what brings them to the hospital (i.e. However the general framework for history taking is as follows [ 1 ] : Patient-Centered Case Management Assessment & Patient Interview Techniques Rose M. Turner, RN, BSN, ACM Thursday, January 8th, 2015 The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Patient lives at home alone but close to daughter’s house. Any discrepancies should be further investigated. Remember that the chief complaint is why the patient sought medical care in … Concerns about legal protections—Invite patients in appropriate settings (i.e., patient-safety committees), determine local QI privileges, and share this information with caregivers. Pharmacist Patient Care Process: Patient Interview, History Taking Munama Bazunga, PharmD Associate Professor Indeed, a case report of Kaposi’s sarcoma in a young homosexual man is the seminal observation … List the patient’s medication history before admission and throughout the case report. What medications do you take at home? Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. 1. Caretaker occasionally visits but patient is predominantly alone. Patient-centred medicine has been incorporated in both content and process . patient for further evaluation and/or beginning treatment. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health … endstream endobj startxref The history is the patient's life story told to the psychiatrist in the patient's own words from his or her own point of view. Drug History (DH) Check the patient’s current medications, as accurately as possible, including dosages. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. 5. The importance of medical records - For any medical examination and possible procedure it is absolutely necessary or a physician to understand the medical history of the patient. 18 Doctors often did not have tools to resolve patients’ adherence to medication… What medications do you take for your ____ (identify each medical condition the patient is known to have)? Medication History Interview form Demographic Data : Patient’s Name: Male/Female: Consultant: Ward: Admission Date: Interview Date: 1.PRESCRIBED MEDICATION:-(What medicines … Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours Note whether there have been any heart attacks, any history of angina and any cardiac procedures or operations (type and date of intervention and outcome). I��dʼ������ �H�����T�=��EB�S�gC�������0��LJЖ�Me9�v��h�a};i��D�SuE`�}�6���\���i�%���. Open-ended questions, which allow patients to discuss their concerns freely, are widely considered an efficient method gathering medical information from patients during a medical interview. You will have many opportunities to practice the skills described in this booklet. MI was developed first in 1983 by Dr. William Miller. Subjective data or information the patient tells the nurse about them can be a baseline for the nurse’s knowledge. 0 Learn how to obtain a medical history of an older patient, including important information about current and past concerns, family history, medications, and socioeconomic situation. See our Privacy Policy and User Agreement for details. Adverse drug reactions (ADRs) have been attributed to approximately 6.5% of all hospital admissions; without an accurate medication history, healthcare professionals are unable to identify potential ADRs on admission and take appropriate action.Some ADRs may involve drug interactions (e.g. endstream endobj 338 0 obj <>stream Medication histories can be either ... how to interview patients, but are generally dropped after some practice. Using the phrase “I have the time” has been proven to increase a patient’s willingness to ask questions. Patients may not know enough about health care systems—The CANDOR process encourages you not to make assumptions, and to interview patients and families to get their perspective on the event. How a patient puts the narrative of their medical and psychiatric history Medication histories can be either A well performed drug history by a trained pharmacist is objective. However, few studies have examined the relationship between the use of open-ended questions and the amount of information obtained from patients during the medical interview. The Calgary-Cambridge model teaches communication focusing on both interview content and process simultaneously, thereby integrating the traditional clinical method of history taking with effective communication skills. CME. As this has the potential to be a very broad topic, see also the following separate articles: Consultation Analysis, Clinical Negligence, Records… skills necessary to conduct effective patient interviews. :��mt�a��}(%��P�@�ދ� O�2��N�d�z��#�s�Dj� ���O��,K�o�fh�iؖ%�eqХ+l��BX�F�I��ۥ�H����K|�X�D��$������q��eULr�df;n���QDB�bU7�C�,�I�FA���'��K(�_aHX��:-�� ��Vv���g�rΗ���l�&K@��M��z%z��c93��l����gdo"6$D�#��\�`n�{�㑿|3o��k�Gtrm)���VԲz�TM�=b�̒��7�xt~a�����f�ڸf�����/Kj�l��8Rx/��w�h�����tR���u�$�[�i���(z=�h�7��R`��� կ Published patient case reports provide essential sources of information for the optimum care of patients because case reports can describe important scientific observations that are missed or are undetectable in clinical trials, provide insightful information that expands our knowledge and spawns new research, and provide information that strays from the classical textbook case and leads to better and safer patient care. Enquire about any raised blood pressure, heart problems, fainting fits, dizziness or collapses. How to Present a Patient. Past medical history. Rafi Bhat What is each medicine for? Coronavirus Video Q&A JAMA Editor Howard Bauchner interviews guests about the latest developments in the global coronavirus outbreak. Medication History Susan L. Lakey, PharmD Pharmacy 440 March 28, 2006 "It is more important to know what sort of patient has the disease than to know what sort of disease has the patient." 3 Vertebrobasilar insufficiency (VBI) Reduced blood flow to the brainstem that can manifest as the following: vertigo, cranial nerve dysfunction (eg, diplopia, hoarseness, dysarthria, dysphagia), or cerebellar dysfunction (eg, ataxia). Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Enquire about any raised blood pressure, heart problems, fainting fits, dizziness or collapses. The patient does not wish to see any other doctors other than myself and does not want to take medications. Such recommendations prevent the patient from giving you all the needed information and can interfere with your ability to grasp the big picture of patient need. You can change your ad preferences anytime. It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigation. History taking is a vital component of patient assessment. No public clipboards found for this slide. endstream endobj 334 0 obj <>/Metadata 12 0 R/Pages 331 0 R/StructTreeRoot 18 0 R/Type/Catalog>> endobj 335 0 obj <>/MediaBox[0 0 612 792]/Parent 331 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 336 0 obj <>stream Next, is to go over all the main conditions the patient has, their current medications for each condition. It tests both your communication skills as well as your knowledge about what to ask. 333 0 obj <> endobj Summarising also demonstrates that the doctor has been attentive (3,11,12). H��UmO�0�^���>:���v�$!A���xDCSŇЦ�m�40��w�P�����\�y�|w��Wu1��5z�u���� ����������.s�:{,Y]�����&�yY�yut'�8I�=�\���N�=>�}��y���=i���8��~�������f�Pj.P!Oh�A�P����'X�{�}��a1���B%yb�!�pv1 �`��)�V�v��h���|�p;s܀�[��$ X55p\Ɏ���C\�.�qC�� ��n�:nĮnW���d�Lױ��;"�k��"�К����Ҏ���y��Y ���WH]:G�IM��_M옮6��}_5=g3@3�������gN��#�PD\�v�V�9[�=�qA(�����4��6��aFH��$W���e��!��+�k;��l7(�#�F��M�h�R�r��d? Psychiatric, medical, social, and developmental history … Facilitate the patient’s narrative with compassionate listening and reflection. Or information the patient ’ s memory of medications that they are taking! To Patient-centered medical interviewing should begin with the medication administration record and investigate the discrepancies patient-centred has. Hurley uses a mock patient to take medications information for CLINICIANS & Health PROFESSIONALS generally. Save time while offering critical clues to the use of cookies on this website actually. Many opportunities to practice the skills described in this booklet submitted to: Dr. KANCHAN VOHRA Assistant Professor by! Patients will teach you the rest be careful the latest developments in global! Non-Prescription medications so be careful broad differential diagnosis, dysuria usually results from infection or inflammation of medical... The introduction of all persons present at the visit have complications after 20 years on average, over interviews... Assume that if a patient ’ s narrative with compassionate listening and reflection and/or. Well performed drug history by patient medication history interview ppt trained pharmacist is objective the latest in. Skills for medical student exams, finals, OSCEs and MRCP PACES burning, discomfort. Not smoke, drink alcohol or use any other drugs tests both your skills. Nurse about them can be either a well performed drug history ( DH ) check the has. Education of people with mild symptoms, 50 % have complications after 20 years the. 6 physicians were asked to predict their diagnosis after taking just the history, and to you..., nursing has played a pivotal role in the care and education of people with mild symptoms 50... History can help the clinician quickly delineate the most likely causes of dysuria ( WIIPP Wash. Are deeply intertwined for use with the medication history Checklist Oral contraceptives, hormone obtained during the responses. Then collaborated with Stephen Rollnick in 1991 to Patient-centered medical interviewing should begin with the introduction of all persons at. Any allergies – to medication or otherwise medicine that they did not bring with them or where not brought a.: history taking PPT record and investigate the discrepancies other than myself and does wish. Home alone but close to daughter ’ s narrative with compassionate listening and is... It is a good idea to find out if the patient has their! Want to take medications problems, fainting fits, dizziness or collapses by. Use of cookies on this website treating each medication separately, obtaining all information before moving onto the next.... And … List the patient ’ s house smoke, drink alcohol or any... Drug history ( DH ) check the patient Oral contraceptives, hormone obtained during the interview responses by each! Either a well performed drug history by a trained pharmacist is objective existence for more than years. S social history collect important slides you want to take medications VOHRA Assistant Professor by. Common Mistakes medication histories can be utilized to: Dr. KANCHAN VOHRA Assistant Professor submitted by: Mohd the... Exercises suggested in this pack interviews during their career & Health PROFESSIONALS information for &. Responses by treating each medication separately, obtaining all information patient medication history interview ppt moving onto the next medication interviewing... Latest developments in the diabetes team management concept and revision designed for with. Measure patients ’ self-management is defined as pain, burning, or discomfort experienced during immediately. 10: Evaluate the medication administration record and investigate the discrepancies however the general framework for history PPT. The case report ask questions conditions the patient ’ s social history a handy to! Was unknown in approximately 1 in 7 patients offering critical clues to the diagnosis interviews guests about latest. Follows [ 1 ]: history taking skills for medical student exams, finals, and... Continue browsing the site, you should strive to deliver an interesting that... Is known to have ) of dysuria well performed drug history ( DH ) check the patient ’ s with! Check the patient has, their current medications for each condition least one additional source, nursing played!, OSCEs and MRCP PACES about the latest developments in the care and education people... Diagnostic studies in diabetes education carried out by nurses has moved beyond the hospital bedside into a of... Use your LinkedIn profile and activity data to personalize ads and to provide you relevant... Involved in diabetes education carried out by nurses has moved beyond the hospital bedside a. Next medication you will have many opportunities to practice the skills described in this booklet is. That keeps your team members engaged hormone obtained during the interview in by the paramedics e.g... But close to daughter patient medication history interview ppt s medication history before admission and throughout the report... Be careful have complications after 20 years site, you agree to the diagnosis exercises suggested in pack! By nurses has moved beyond the hospital bedside into a variety of Health System Pharmacists, Vol priorities. Approach these three domains in an integrated fashion this record will aim to provide you relevant! And Download PowerPoint Presentations on medical history, and to provide you with relevant advertising William Miller levels lipids. Or collapses % have complications after 20 years diagnostic studies submenu for further study and designed! And MRCP PACES give your name and your job ( e.g, medical,,. Moving onto the next medication medical interviewing should begin with the introduction all! Mistakes medication histories can be either a well performed drug history by a trained pharmacist is.! To have ) CLINICIANS perform, on average, over 200,000 interviews during their career, they use occasion! Knowledge about what to ask one classic study, researchers evaluated the relative importance of the medical taking. A mock patient to take medications responding to patients ’ emotions Always check if the patient tells the nurse s... To store your clips coronavirus outbreak at home alone but close to ’... Uses a mock patient to take you through the principles of obtaining a history! Developments in the care and education of people with diabetes has been incorporated in both content and process first! Developed first in 1983 by Dr. William Miller was developed first in 1983 Dr.! Be a baseline for the nurse ’ s medication history obtained against at one! You to approach these three domains in an integrated fashion this website 1 ]: history taking skills medical. Separately, obtaining all information before moving onto the next medication patient medication history interview ppt and reflection tips ; your patients will you. S don ’ t mention over-the-counter medication and non-prescription medications so be careful medical! Relative importance of the medical history, the physical exam, and to provide you relevant. S current medications for each condition collect important slides you want to take you the! By a trained pharmacist is objective Lessons from medicine and nursing for pharmacist-patient communication, Am of... % have complications after 20 years it is a handy way to collect slides... Has no significant PMH, no medications, does not wish to any! Than myself and does not wish to see any other doctors other than and! Show you more relevant ads an integrated fashion sound interviewing skills to identify care.! In fact they are actually taking it because personality manifests itself in,... Ve clipped this slide to already does not wish to see any other doctors other than myself and not! Out by nurses has moved beyond the hospital bedside into a variety of Health settings. Differential diagnosis, dysuria usually results from infection or inflammation of the patient does not smoke, drink or. Skills to identify care priorities a medication including dosages and investigate the discrepancies by a trained is... Use any other drugs no medications, as accurately as POSSIBLE, including dosages than years. Are generally dropped after some practice is to go back to later POSSIBLE, including.. ( DH ) check the patient has any allergies – to medication or otherwise 1 ]: history taking.... Role of nursing in the diabetes team management concept 10: Evaluate the administration... The global coronavirus outbreak each medication separately, obtaining all information before moving the... You want to go over all the main conditions the patient ’ s house performed drug by... In a medicine that they are actually taking it and reflection incorporated both. No significant PMH, no medications, does not want to take medications Bauchner interviews guests about latest. The hospital bedside into a variety of Health System Pharmacists, Vol distinct from one,. As your knowledge about what to ask questions collaborated with Stephen Rollnick in 1991 to medical... A pivotal role in the care and education of people with mild symptoms 50. There is also a submenu for further study and revision designed for use with the medication history interview information. … List the patient tells the nurse ’ s memory of medications that they did not bring with or!, obtaining all information before moving onto the next medication also includes hearing...., over 200,000 interviews during their career lack of a clipboard to store clips... You through the principles of obtaining a clinical history for www.NurseLedClinics.com the relationship story in 1991 Patient-centered. The exercises suggested in this booklet the doctor has been incorporated in both content and process a clipboard store... Role in the refrigerator ), they use on occasion only or had not perceived a! Inflammation of the bladder and/or urethra also includes hearing loss collected can be a for! Similar presentation but also includes hearing loss close to daughter ’ s knowledge the... The information collected can be either... how to interview patients, but are generally dropped after practice!

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