Shadow Health Conversation Notes – Flashcards
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A proper greeting:
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1) uses a friendly tone 2) addresses both yourself and the patient by name 3) States your reason for being there
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The narrowing and broadening of scope in a health history interview occurs in the contexts of:
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an organized progression through topics related to patient health
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How to structure a health interview
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Greeting and identifying data Chief Complaints History of Present Illness (HPI) Family History Personal and Social History Review of Systems
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Greeting and Identifying Data
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Greet patient and confirm patients name, age, and gender
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Chief Complaint(s)
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Identify symptoms or concerns causing patient to seek care
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History of Present Illness (HPI)
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Assess symptoms and patient's thoughts and feelings about illness
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Medical History
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Determine allergies, presence and dates of childhood and adult illnesses, chronic health problems, immunization history, and past hospitalizations
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Family History
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Determine age and health, or age and cause of death, of parents, sibling, and grandparents, noting the presence of specific illnesses in family (e.g. hypertension, addiction, type II diabetes).
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Personal and Social History
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Evaluate education level, family and household dynamics, spiritual practices, personal interests, sleep habits, and lifestyle (e.g. tobacco, alcohol and illicit drug use, sexual history, exercise, and nutrition
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Review of Systems
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Assess the presence or absence of common symptoms related to each major body system.
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To Shape patient interviews
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Move from open questions to closed questions (shaped like a cone)
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Open questions
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"cast a wide net" - allow patients to communicate more generally, and allow them to emphasize their own concerns and priorities
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Open question examples:
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How did you injure your elbow? What are your stomachaches like? What prevented you from refilling your prescription? How have you been managing your blood pressure
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Key Open Question Words
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"Describe", "Tell me about", "How", "Why"
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Open Question tips
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- Ask the patient to elaborate or describe - Convey empathy and avoid judgement - Avoid unnecessary use of medical terminology or jargon - Use concise language to convey a clear meaning.
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Closed Questions
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"zoom in" on particulars and refine their understanding of an aspect of patient health
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Closed Question examples
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- Has your pain gotten worse? - Are your headaches focused on one side of your head? - Has the medication helped with your heartburn? - When did you start feeling fatigued?
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Key Closed Question words:
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"How many", "How Often", "Can you, do you, will you, are you", "is it, has it, have you, etc", "Which", "Who"
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Open or closed questions establish therapeutic rapport?
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Closed. Good for: - Sexual History - Substance use - Social or domestic problems - Trauma - Physical symptoms that the patient finds embarrasing
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for Conversational Flow:
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Move between open and closed questions.
