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PHA 3785Therapeutic Communication
and Health History
Debra A. Allan Danforth, MS, ARNP, FAANP
FAMU College of Pharmacy12/10
Legal and Ethical Issues
Legal refers to action or inactions that may be held accountable by law, particularly criminally, and also civil
Ethics moral principles or standards of conduct, and may be held accountable in civil court
Legal and Ethical Issues
Autonomy Beneficence Nonmaleficence Utilitarianism Fairness and justice Deontologic imperatives
Privacy
Refers to the individual and their affairs (Ex. The right to be left alone) Person’s name Invasion of privacy Breach of confidentiality Autonomy
History and Communication
What Is Assessment?
A data collection process A continuous process Establishes a baseline A systematic process Identifies patients’ strengths and
limitations Involves collecting, validating, and clustering data
Purpose of Assessment
Collect pertinent patient health status data
Identify abnormal findings
Identify patients’ strengths and coping resources
Pinpoint actual health problems
Identify risk factors for health problems
Assessment SkillsCognitive SkillsAssessment is a “thinking process” Inductive and deductive reasoning
Ex. Inductive: used when assessing a post-op patient who state it hurts to take a deep breath
Piece together pertinent data
Ex Deductive: patient is admitted to hospital with CHF. Will look for specific signs and symptoms as you perform the assessment and determines patient’s response to illness
Looking for specific clues to support
Clinical decision making
Assessment SkillsProblem solving
Reflexive thinking Is automatic, without conscious deliberations and comes
with experience Trial and error
Is hit or miss thinking-random, not systematic and inefficient
Scientific method Is a systematic, critical thinking approach to problem solving
Intuition Is a problem-solving method that develops through
experience
Assessment Skills
Psychomotor SkillsAssessment is a “doing” process
Skills needed to perform the 4 techniques of physical assessment Inspection Palpation Percussion Auscultation
Assessment Skills
Interpersonal/Affective SkillsAssessment is a “feeling” process
Affective skills needed to develop caring, therapeutic healthcare provider-patient
relationships Include verbal and nonverbal Establish trust and mutual respect
Assessment Skills
Ethical Skills
Assessment is being responsible and accountable
Responsible & accountable for practice patient advocate Respect patients’ rights Assure confidentiality
Types of Assessment
Comprehensive Ongoing/Partial Problem focused Emergency
Types of Data
Subjective Definition: Of, relating to, or designating a
symptom or condition perceived by the patient and not by the examiner.
Objective Definition: Indicating a symptom or condition
perceived as a sign of disease by someone other than the person affected.
Identify Subjective or Objective
Headache BP 170/110 Nausea Diaphoresis Equal pupil reaction Dizziness Slurred speech Numbness in left arm
Therapeutic Communication
Central Objectives of Interacting with a patient To find out what is at the root of that
person’s concern To help them in doing something about What does a patient need? What is the patient worried about? What does the patient expect of you?
History and Physical
The heart of the diagnosis and treatment process
Must be done in an orderly process Must also be sensitive to the “soft” cues
that are almost always there
Goals of Patient Interview
Information discovery Providing information to the patient Negotiating with the patient regarding
treatment management Counseling regarding disease
prevention
Ineffectiveness of Most Communication Most people do not communicate well Causes an interpersonal gap and
isolates people from each other
Communication Barriers
A barrier to communication is something that keeps meanings from meeting
Without realizing, people typically inject communication barriers over 90% of the time when one or both parties has a problem to be dealt with or a need to be fulfilled
Why are they High-Risk Responses? They block conversation Increase emotional distance between
people Thwart the other person’s problem-
solving efficiency
Categories of Barriers
The “Dirty Dozen” of barriers to communication can be divided into three major categories Judging Sending Solutions Avoiding Other’s Concerns
Judging
Criticizing Name-calling Diagnosing
Sending Solutions
Ordering Threatening Moralizing Excessive/Inappropriate Questioning Advising
Avoiding the Other’s Concerns
Diverting Logical Argument Reassuring
Listening: More Than Merely Hearing Listening refers to a more complex
psychological procedure involving interpreting and understanding the significance of the sensory experience
Listening Skill Clusters
Attending Skills A posture of involvement
Appropriate body motion
Eye contact Nondistracting
environment
Listening Skill Clusters
Following Skills Door openers Minimal
encouragers Infrequent questions Attentive silence
Listening Skill Clusters
Reflecting Skills Paraphrasing Reflecting feelings Reflecting meanings Summative
reflections
Paraphrasing
Concise response Essence of content Listener’s own word
Reflecting Feelings
Improve capacity to “hear” feelings Listening for feeling words Inferring feelings from the overall
content Observing body language “What would I be feeling?”
Reflecting Meanings
“You feel…because” Validation of Data
Using technical terms Not allowing patient to finish answer Too many questions Failure to find out patient’s interpretation
Summative Reflections
Brief restatement of main themes and feelings speaker expressed
Gives speaker feeling of movement in exploring content and feeling
Interview –Communication Techniques Open Ended Questions Closed Questions Affirmation/Facilitation Silence Clarifying Restating Active Listening Reflection Humor
Informing Redirecting Focusing Sharing Perception Identifying Sequencing Events Suggesting Presenting Reality Summarizing
Open End Questions
Advantages Elicits a response Effective in stimulating descriptive or comparative
responses Allows patient to disclose information when he/she
is ready Provides clues to alertness, level of mental
abilities, organization of thought through vocabulary
Rapport is strengthened
Open End Questions
Disadvantages Response not relevant Digress to avoid disturbing data Anxiety increased if not articulated
Closed Questions
Advantages Requires no more
than 1-2 words Used more initial
interview
Disadvantages Limits answers
Affirmation/Facilitation
Acknowledge patient’s response through verbal and nonverbal response
Reassures you are listening Nodding, sitting up and leaning forward
are nonverbal ques Verbal cues
“ah ha”, “go on”, “tell me more”
Silence
Silence allows patient to collect thoughts before responding and help prevent hasty responses
More uncomfortable for interviewer than interviewee
Gives interviewer time to think and plan response
Focus on patient’s nonverbal behavior
Clarifying
If unsure or confused what patient says, rephrase “let’s me see if I have this right” “ I’m not sure what you mean”
Restating
Restating the main idea shows the patient that you are listening, allows acknowledgement of feelings, and encourages further discussion
Also helps to clarify and validate what your patient has said and may help identify teaching needs “I take a water pill every day for my blood
pressure” “I see you take Lasix for your blood pressure”
“NO, I take a water pill”
Active Listening
Pay attention Eye contact Listen to what patient tell you both
verbally and nonverbally Conveys interest and acceptance Watch your own body language
Reflection
Acknowledge patient’s feelings “I’m afraid of having surgery”
“You’re afraid of having surgery?”
Encourage further discussion
Humor
Can be very therapeutic Reduces anxiety Helps to cope more effectively Puts things into perspective Decreases social distance
Informing
Giving information helps the patient with making decisions on their healthcare Teaching pre-operatively how to do a
procedure post-operative like coughing and deep breathing can help the patient in the long run
Redirecting
Helps to keep communication
goal-directed To get back on track
“Getting back to what brought you to the clinic…”
Focusing
Allows to hone in on a specific area Encourages further discussion
“Do you do SBE?” “Have you had a MMG?” “Do you do a testicular exam?”
Suggesting
Presenting alternative ideas gives your patient options
Helpful if patient is having difficulty verbalizing feelings
Good teaching tool “I’ve tried to lose weight and I can’t”
“Have you tried diet and exercise”
Summarizing
Useful conclusion Allows patient to clarify any
misconceptions “let me see if I have this correct”
Three Essentials for Effective Communication Respect Genuineness Empathy
How to Demonstrate Respect for Patient Introduce yourself clearly and explain your
role Do not use patient’s first name during initial
interview without permission Inquire about and arrange for patient comfort
before getting started and during Warn patient when going to perform
something painful or unexpected Respond to the patient that shows you have
heard what they have said
Genuineness
Be open, honest, and sincere Can detect a less-than honest response or
inconsistencies between verbal and nonverbal behavior
The ability to be yourself in a relationship despite your professional role “introduce yourself as a nursing student, pharmacy
student, nurse practitioner, pharmacist, etc.”
Empathy
Sensitive and accurate understanding of the person’s feeling while maintaining a certain separateness from the individual
Understanding the situation that contributed to or “triggered” the feelings
Communicating with the other in such a way that the other feels accepted and understood
Patient-Centered Clinical Method
What does it mean to be patient-centered? It means much more than merely being
“nice” or “kind” or “compassionate” to the patient.
Patient-Centered Clinical Method
Is an evidenced-based, conceptual method of practice consisting of the following interactive components:
Exploring both the objective disease processes and the patient’s subjective illness experience
Striving to understand the whole person and how the illness impacts their life and how their life context influences risks for and responses to disease
Finding common ground between the pharmacist perspective and understanding and that of the patient as it relates to the problem, treatment, and expectations
Patient-Centered Clinical Method
Shared decisions about how best to approach the patient’s problem
Finding opportunities to incorporate prevention and health promotion into the process of care
Recognizing that the patient-pharmacist relationship is a powerful resource and essential to the health and well-being of both participants in the relationship
Relationship Building
Introduce yourself and explain your role ie: Patricia Dee, 5th year pharmacist student
Using polite forms of address ie: Mr., Mrs., Ms., Dr.
Listening Attentively Establish eye contact Assume an attentive body posture Establish a comfortable spatial position and distance Minimize distracting behaviors like excessive note-taking or
reading and talking at the same time Use summary statement
Relationship Building Skills
P - partnership E- empathy A- apology R- respect L- legitimation S- support
Partnership
Partnership – explicit statement to the patient indicating your willingness to work together in an effort to accomplish therapeutic goals If you would like I’d be happy to review the
plan with you to see if any adjustments need to be made.
Empathy
Empathy – capacity to recognize a patient’s feelings or emotional reactions I know it must be frustrating for you to be
on this diet and not see much progress.
Apology
Apology – willingness and ability to acknowledge to another person that you may be in part responsible for a negative outcome, discomfort, ill feelings, etc. I’m sorry if I gave you the impression that I
didn’t think you were trying to watch your weight.
Respect
Respect – willingness to consider another person “worthy of regard”; show respect for another person by being non-judgmental and setting aside personal feelings in order to be helpful and caring I admire you for continuing to make the
effort.
Legitimation
Legitimation – intervention that explicitly communicates acceptance of the patient’s affect or feelings I think most people would feel frustrated
and want to give up.
Support
Support – explicit statement conveying your willingness to be available to the patient in a helping capacity Please let me know if there is anything that
I can do.
Non-Verbal Communication
Non-verbal SOFTEN Skills: Listening is as important asspeaking and these non-verbal skills facilitate thedemonstration of active listening.
S- smile O- open posture F- forward lean T- touch (caring, reassuring) E- eye contact N- nod
Health History
Practical Points for History Taking Use a quiet, sympathetic but confident tone of
voice Make your questions simple and brief Allow plenty of time for patient to express or
explain, before you clarify or continue Clarify inconsistencies between sources or
interpretations in non-threatening or non-persecuting manner
Practical Points for History Taking Avoid asking patient for information that they
are not likely to have as this can increase anxiety or mistrust about unknown
Ask only appropriate questions Use terminology appropriate to their social,
cultural and educational status Use significant others, when present, to
clarify points that seem to be vague If a child is distracting, provide attention
devices
Pitfalls
Leading the patient People will tell you what you want to hear Do not lead the patient Let them tell you in their own words
Biasing yourself Because of the patient, disease or health care
provider
Letting family members answer for patient Need to let patient answer questions
Pitfalls
Asking more than one question at a time Not allowing enough response time Using medical jargon Assuming rather than clarifying/validating Taking the patient’s response personally Feeling personally uncomfortable
Pitfalls
Using clichés Offering false reassurance Asking persistent or probing questions Changing the subject Taking things literally Giving advise Jumping to conclusions
Pitfalls
Data Collection Omission of pertinent questions Omission of pertinent negatives Failure to elicit temporal relationships
precisely Failure to elicit follow-up important leads
Pitfalls
Structure Beginning too fast Allow patient to ramble Needless repetition of questions Poor transitions Covering delicate areas too early
Pitfalls
Practitioner Attitude Acting too friendly or not friendly enough Not listening
Lack of eye contact
Not enough interest or too much interest in emotional factors
Phases of the Interview
Introductory Is the time to introduce yourself to the patient,
purpose of the interview and the time frame needed to complete
Working Where data is collected, very structured, and the
longest phase. Need to listen what is said verbally/nonverbally
Termination Need to summarize and restate findings
Components of the Health History
Identifying info Chief Complaint or Chief Concern (CC) History of Present Illness (HPI) Functional History (FxH) Past medical history (PMH) Family history (FH) Personal and Social (SH) Review of systems (ROS)
Biographical Data
Name Address Phone Number Social Security # Contact Person Age (Birth Date) Gender Race/Ethnicity
Religion Marital Status Number of
Dependents Educational Level Occupation Insurance Advance Directive Reliability
Identifying Info
Name Age (Birth Date) Gender
Chief Complaint/Concern for Seeking Healthcare
What can the patient’s reasons for seeking health care and the patient’s current health status tell you?
Current Health Status/Present Problem or Illness Primary Level
Usual state of health Any major health patterns Unusual patterns of health care Any health concerns
Secondary and Tertiary Perform a Symptom of Analysis (AOS)
Symptom Analysis
P = Precipitating / palliative factors
Q = Quality / quantity of symptom
R = Region / radiation / related symptoms
S = Severity
T = Timing
Symptom Analysis
O: Onset L: Location D: Duration C: Character A Aggravating/
Associate
Factors R: Relieving Factors T: Temporal Factors S: Severity
O: Onset L: Location D: Duration C: Character A: Aggravating/
Associate
Factors R: Related symptoms T: Treatment S: Severity
Analysis of Symptoms “Sacred 7” chief concern Location-radiation Quality Quantity Time
Onset Duration Frequency Progression over time
Setting/Context Aggravating Factors
Relieving Factors Associated Symptoms Similar symptoms in
past Explanation why
concern presented now Theories or worries
about causes / implications
Impact of symptoms
Functional Assessment
Activity of Daily Living (ADL’s) Dressing, Grooming, Feeding, Bathing
Instrumental Activities of Daily Living (IADL’s) Driving, Cooking, Using medication
Advanced Activities of Daily Living (AADL’s) Work, Church, Recreations
Functional History ADLs; one’s basic personal care
Listed in order of hardest to easiest to perform Minimum requirement to live home alone Represent primarily physical ability Acquired by the first time one leaves home (about 6
years old; off to kindergarten) IADLs; one’s ability to manage home life for them
self Represent cognitive component in addition to physical
ability Acquired by the second time one leaves home (about 16
years; off to college, career, etc.; the things mom and dad won’t be doing now)
AADLs; what makes life meaningful, not necessarily essential for survival (as ADLs and IADLs are) Often correlate with quality of life measures
Past Medical History General Health and Strength Major Adult Illness
(Serious/chronic) Psychiatric conditions Medications
Prescription OTC Alternatives
Allergies Hospitalizations Surgeries Serious Injuries/Accidents Transfusions
Childhood Illness Menstrual Cycle (females
only) Depression Screenings
Blood pressure Diabetes Cholesterol Mammogram Stool for occult blood Colonoscopy
Immunization
Family History
Patient Grandparents Parents
Siblings Spouse/Significant
other Children
Genogram
Personal and Social History
Education Marital Status Home condition Occupation Military record Cost of Care Sexual History Domestic Violence Living Will/ Healthcare
surrogate
Habits Tobacco Alcohol Recreational Drugs Exercise Sleep and Rest
Nutrition and diet Coffee, Tea Special Diet
Religious preference Cultural Requirement
Assessment of Domestic Violence
HITS (Sherin et al, 1998) H Hurt you physically? I Insult or talk down to you? T Threaten you with physical harm? S Scream or curse at you?
Assessment of Exercise
FIT acronym to ask about exercise regimen F is for FREQUENCY of the activity I is for the INTENSITY of the
activity T is for the TIMING, or duration, of the
activity
Assessment of Substance Abuse Abuse of alcohol and other substances is a highly
prevalent problem Healthcare providers must assess for such behaviors
because of implications for complications of illness Two types of tools used to assess alcoholism
CAGE TACE
The history of alcohol consumption and dependency can further be assessed by using the questionnaires HALT BUMP FATAL DT
CAGE
C: Are you CONCERNED about your drinking?
A: Are you ever ANNOYED when someone questions the amount you drink?
G: Do you ever feel GUILTY about your drinking?
E: Do you feel you need an EYE-OPENER in the a.m.?
TACE
T: How many drinks does it TAKE to make you feel high?
A: Have people ANNOYED you by criticizing your drinking?
C: Have you felt you ought to CUT down?
E: Do you feel you need an EYE-OPENER in the a.m.?
HALT
H Do you usually drink to get HIGH? A Do you drink ALONE? L Do you ever find yourself LOOKING
forward to drinking?
T Have you noticed whether you seem to be becoming TOLERANT
of alcohol?
BUMP
B “Have you ever had BLACKOUTS?” U “Have you ever used alcohol in an
UNPLANNED way?” M “Do you ever drink alcohol for
MEDICINAL reasons? P “Do you find yourself PROTECTING
your supply of alcohol?”
FATAL DT
F “Is there a FAMILY history of alcoholic problems?”
A “Have you ever been a member of ALCOHOLICS Anonymous?”
T “Do you THINK you are an alcoholic?” A “Have you ever ATTEMPTED or had
thoughts of suicide?” L “Have you ever had any LEGAL
problems related to alcohol consumption?” D “Do you ever DRIVE while intoxicated?” T “Do you ever use TRANQUILIZERS to steady
your nerves?”
Review of Systems
General Health Survey
Diet Integumentary
Skin Hair Nails
HEENT Head and Neck Eyes Ears Nose and Sinuses Mouth and Throat
Review of Systems
Respiratory Cardiovascular Breast Gastrointestinal Genitourinary Female
Reproductive
Male Reproductive Musculoskeletal Neurological Endocrine Hematologic/
Immune
Physical Exam General appearance Vital signs Head, neck Eyes, ears Chest, pulmonary Heart, peripheral vascular Skin Abdominal Musculoskeletal Mental status Neurological Female genital, breast Male genital, rectal
How do you document the encounter?
Documentation
SOAP SOAPIE DAR PIE Narrative Electronic Medical Records
Documentation
Be accurate and objective. Use acceptable abbreviations. Be brief and to the point. Document in short phrases. Avoid “normal, usual, general, unremarkable” Record pertinent negatives. Include all required components
Include only subjective in S Include only objective in O
Associate each plan with corresponding assessment Date and sign documentation.
Subjective Definition: Of, relating to, or designating a
symptom or condition perceived by the patient and not by the examiner. Begins with chief concern Includes all of HPI Portions of Functional history Portions of PMH Pertinent SH, FH Pertinent ROS
Objective Definition: Indicating a symptom or condition
perceived as a sign of disease by someone other than the person affected. Begins with general observations Includes vital signs Includes systems based exam based on
symptoms and understanding of anatomy/physiology/pathology
Diagnostic data: laboratory, x-ray, etc.
Sample SOAP Note (With Errors)SubjectiveCc: “she says she has a sore throat”51 year old female appears her stated age, alert, cooperative in no acute
distress. Patient was well until 2 days ago when she awoke and noticed a sore throat, progressively worse throughout the day. Pain is constant, “scratchy” ache, rated 4/10, and radiates to the right ear with swallowing. Pain is aggravated by swallowing; relieved with salt water gargles and Chloraseptic spray.
ObjectiveTemp 98.7 F but she says she felt hot, PR 60 bpm, RR 14 bpm, BP sitting
R arm 110/70Throat: she says she has a lump in her throat; tongue not coated, uvula
midline without ulcerations, tonsils prominent with erythema but no exudates
Lungs: clear to auscultation without wheezing AssessmentShe’s worried this is Strep throatPlanDiagnostic tests: throat cultureTreatment: patient asked for antibioticsPatient education: Associates degree in information technology
Sample SOAP NoteSubjectiveCc: “My throat is really sore”Patient was well until 2 days ago when she awoke and noticed a sore throat, progressivelyworse throughout the day. Pain is constant, “scratchy” ache, rated 4/10, and radiates to theright ear with swallowing. Pain is aggravated by swallowing; relieved with salt water gargles andChloraseptic spray. She reports feeling hot but has not measured her temperature and feels the sensation
oflump in her throat, mostly on the right side. She believes this could be Strep throat and is concerned she
iscontagious to others. She has a history of Strep throat in high school with similar symptoms. Objective51 year old female appears her stated age, well developed, well nourished, alert, cooperative in no acuteDistress with no notable characteristics.Temp 98.7 F (orally), PR 60 beat per minute, RR 14 breaths per minute, BP sitting R arm 110/70mmHgThroat: tongue not coated, uvula midline without ulcerations, tonsils prominent with erythema but no
exudatesLungs: clear to auscultation without wheezing Assessment1. Possible Strep throat2. Medication renewal: SynthroidPlan1. Diagnostic tests: throat culture Treatment: antibiotics if throat culture positive Patient education: medication schedule, change toothbrush, encourage oral hydration 2. Diagnostic tests: blood TSH level in 6 months Treatment: Synthroid 100mcg po qd Disp 30 day supply with 5 refills Patient education: review symptoms of hypo and hyperthyroidism
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