initiating the session
preparation
establishing initial rapport/intro greet patient and confirm name introduce name role and nature of interview ask for permission to proceed
i am here to practice my communication skills which involves us talking about why you came in today and a bit more about you and your life
extra: attend to patient comfo rt
Identify the reason for consultation ask open question on why patient has come in today confirms list of things and screens for further issues negotiates agenda
gathering information
Encourage the patient to tell the story of the problems from when they first started to now ask biomedical and personal questions
Symptoms:
SWEAT - M // for general symptoms
socrates for pain but can be modified well for other symptoms site onset charater/quality radiation alleviating timing exacerbating severity
different question sets for different systems effected
MSK:
pain
heat swelling
stiffness weakness
locking instability
deformity altered functional capacity extraatricular symptoms: red eyes, dry mouth, ulcers, or skin rashes
ask for patients perspective, ideas, concerns, beliefs
Feelings ideas //what are some of your thoughts on this that you havent mentioned already? concerns effect on life expectations
Ask background information:
have you ever been to the hospital for anything
do you have any medical conditions present and past
medication present and past
allergies present and past
familial history of condition
Personal and social history home and support work diet physical activity interests
Screening questions
alcohol smoking vaping recreational drug use
appropriate behaviours:
moving form open to closed techniques clarifies unclear statements summarises clear language be attentive of body language