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