Session 11 Clinical Skills 1 · · 2016-09-06Session 11 Clinical Skills 1 ... • Subjective vs Objective information (S vs OAP, ... • e.g. client reports or suspects gluten intolerance

HMCL211

www.endeavour.edu.au

Session 11

Clinical Skills 1

Naturopathic/Nutritional Medicine

Departments

© Endeavour College of Natural Health www.endeavour.edu.au 2

Introduction

o Case-taking skills & SOAP algorithms

o Models for organising information and

making informed decisions

• Introduction to SOAP note documentation

• Subjective vs Objective information (S vs OAP,

symptoms versus signs), how to differentiate data

• Professional communication & interaction

• Building patient/practitioner rapport

• Asking the right questions (leading, open-ended)

• Prioritising information


Client Care

o Client Care is essentially about TWO things:

Evaluation & Management

o Evaluation, like it sounds, is essentially

determining what we believe is going on;

o Management, of course, is what we intend to

do about it.


Client Care

o On a clinical level:

o Evaluation is more specifically the history and

case-taking, the examinations and everything

that leads to our assessment.

o Management is therefore the therapeutic

strategy and treatment plan(s).

Image: Experienced strategic planner,

www.rtacpa.com, viewed 26th November 2014

http://www.rtacpa.com/


SOAP

o A common, globally used acronym that is

helpful in describing and organizing client care

is SOAP:

• S=Subjective

• O=Objective

• A=Assessment

• P=Plan


SOAP

o SOAP serves as evaluation tool which helps

provide a rationale for plan(s)

o SOAP note documentation systems are used

by all types of providers (Acupuncturists,

Nutritionists, Naturopaths, Nurses, GP’s,

Surgeons) across the world. Once

understood, it is a simple and very helpful

system to implement.


SOAP

o Effective SOAP documentation help you to:

• Organise the clinical data.

• Facilitate clinical reasoning.

• Effectively communicate essential

information to other health care

professionals involved in client care e.g. the

supervisor, student colleagues.


Subjective Data

o S (Subjective) data is essentially the client's

experience. It includes:

• What they FEEL; their SYMPTOMS.

• It’s the client's description of their

presenting complaint and information given

by the client or caregiver.

• Things observed about the client

(Holle, 2014)


Subjective Data

o S (Subjective) data may be gathered from:

• The presenting complaint (PC)

• The history of illness

• The past medical history

• Family history

• Social history

o What are some examples of subjective data?


Objective Data

o O (Objective) data is what we (the clinician)

can appreciate including:

• What we can see or MEASURE.

• The client's SIGNS.

• Information gathered by verifiable means

• Only pertinent data included

o What are some examples of objective data?


Objective Data

o O (Objective) data may be gathered from:

• The primary source is physical examination but O

also includes laboratory values and diagnostic

tests/procedures

• Vitale signs – temperature, pulse, RR and BP

• Weight, height and waist measurement

• Physical examination – CV, skin, Iris, tongue, etc

• Nutritional signs examination – deficiency signs

• Laboratory evaluations – lipids, iron studies, urine

• Diagnostic tests – X-ray, CT, MRI scans

(Holle, 2014)


Assessment

o A (Assessment) is the evaluation of the

collected subjective and objective information.

o This stage involves critical thinking by the

practitioner.

o The assessment of what is happening for the

client serves as a rationale for the treatment

plan(s)

o The assessment stage is always client and

encounter specific (i.e. individual)

(Holle, 2014)


Plan

• P (Plan) is perhaps the easiest to understand; it is

the action steps and treatment plan needed for

each identified and assessed problem.

• The plan consists of the therapeutic strategy, the

treatment aims (both short- and long-term),

prescription, expected outcomes and any

necessary follow-up.

• PLAN may very well include referrals, additional

investigations.


SOAP

o A simple way of understanding the relevance

of SOAP algorithms and how to implement

them in client care is:

S + O = A P o The Subjective + Objective data combine to

lead us to the Assessment which ultimately

drives our Plan.


SOAP

o Potential issues with SOAP:

• Speaking: Poor elocution skills.

• Acquisition of Knowledge: Topic specific knowledge

deficits (facts or experience).

• Facts: Reports incorrect facts or omits facts.

• Expectations: Unaware of needs of listener or

standards.

• Reasoning: Omits or incorrectly applies clinical

reasoning.


SOAP

Group Discussion:

o How might SOAP fit into client encounters?

o How might SOAP effect data collection?

o How might SOAP determine chart notes?

o How might SOAP specifically incorporate the

principles of Natural Medicine:

• First do no harm

• Find the cause

• Treat the whole person


Professional Communication &

Interaction

Practitioner - Practitioner


Professional Communication

o As discussed in Session 6, the need for

effective inter-professional communication is

important for:

• Effective integrative health care for clients

• Risk minimisation with regard to conventional and

CAM interactions and client safety events

o To this end, standardised formats provide a

way of minimising barriers and improving

communication e.g. SBAR(Pierantozzi, 2013)



(Pierantozzi, 2013)



From Primum Non Nocere: “As one GP registrar

describes:

When a client presents with a list of tests

requested by the naturopath without any

explanation as to why they are even needed,

this just leaves a sour taste in my mouth. If I

have to converse with another treating physician

the least I do is write a letter of referral. It’s an

integral component in the continuity of the

client's care.”(Pierantozzi, 2013)


Referral

o Referral should be made when client’s needs

cannot be met by practitioner

o Should be done in consultation with client

o Should not be done to avoid “difficult and

unenjoyable work”

o Useful in case of people with special needs,

e.g. cultural and language differences

(Geldard, 2009)


Referral

Referral Letter

o Use SBAR or similar convention

o A summary of the key medical facts will save

time and assists the other practitioner in

clinical decision making.

o Outline important points of reference e.g.

• Jenny Smith (PCOS diagnosed 2011, Metformin

500mg TDS)

(Pierantozzi, 2013, Arthur, 2014)


Referral

o Use medical language and conventions

• Avoid ‘naturopathic language’ e.g. adrenal

fatigue, leaky gut, immune modulating

• Include all units of measurement

• Use tables to summarise medical history if

extensive

o Report accurately

• e.g. client reports or suspects gluten intolerance

• Use quotation marks when reporting the client's own

words.

(Arthur, 2014)


Referral

o Be reasonable with your requests

• Choose the tests that are indicated. A request for

tests is not a ‘wish list’.

• Know which tests you can request e.g. T3, T4 and

RT3 can’t be subsidised without a prior diagnosis

of thyroid disease or TSH outside of reference

range.

o Provide a rationale

• Present a clear justification for any requests

– e.g. Iron studies (vegetarian diet)

• Include references where appropriate

(Arthur, 2014)


Best Practice

o If a client is referred to you by another

practitioner, medical or complementary it is

standard practice to follow up with the

referring practitioner.

• If the client isn’t going back to the referring

practitioner, you may just send an email to thank

them.

• If you will be working with the referring practitioner

you would send a more comprehensive report

back about the client you have in common.


Best Practice

o If the client is part of an integrative team of

practitioners including the referring

practitioner e.g. acupuncture,

musculoskeletal therapist and naturopath

you may provide your client with a report to

share or communicate with all parties.

o While you may not receive the same

courtesy in return, best practice should be

adopted when working with both medical and

complementary practitioners.


CommunicationActivity:

o Review the Template referral Letter. (Lecturers

are to access this via the Clinic Hub on the

LMS under the Nutrition or Naturopathy Green

Tab and project it on to the board for this

exercise).

o View and discuss Referral Letter Example 1

and 2 from your weekly readings.

o For more about interprofessional

communication read: Primum Non Nocere

from your weekly readings.


Building patient/practitioner rapport


Conflicting Views

o Responsibility for good interaction tends to be seen by

clients as the responsibility of the practitioner.

o Conventional medical contact can be seen as:

• Getting information out of clients

• Imparting information to clients

• <5% of doctor’s comments is friendly or sociable

• 25% of medical consultations, the chief concerns had

not been elicited. (Persaud, 2005)

o Take care that you don’t just see your client as a

source of information.


Rapport Building and Relationship

Maintenanceo Rapport building is an integral part of

developing an ongoing practitioner/patient

relationship.

o A strong relationship is essential for effective

clinical encounters.

o A warm greeting, eye contact, a brief

personal/non-medical interaction, checking in

on family or an important life event can take

less than 5 minutes but builds client trust and

connection.(Mauksch, 2008)


Rapport Building

o Caution, if you haven’t established

connection with your client, there may be

insufficient trust to engage in small talk.

o Don’t engage in too much small talk as it

may railroad the reason for the consultation.

o As the relationship develops, ‘check-in’ with

your clients to re-establish the relationship.

(Mauksch, 2008)


Acknowledging

o Clients often give clues to indicate thoughts

or feelings relating to their illness or

behaviour.

o Acknowledge these in an empathic way – it

may allow the client to reveal beliefs about

illness, preferences about treatment/care or

underlying drivers of illness.

o Empathy (not sympathy) can help focus a

discussion and/or invite further exploration of

issues. (Mauksch, 2008)


Non-verbal communication

o Pick up non-verbal cues from your clients.

• Are they distressed?

• What is their mood like and how do their demeanor

and body language change during the

consultation?

o This may give clues to difficulties they may have

that they cannot express verbally.

o If people become uncomfortable during a line of

questioning, their body language may become

“closed”; they may cross their arms and legs and

fail to keep eye contact.


Habits to Avoid

1. Dismissing the subject matter as uninteresting

• it may vitally be interesting to the client

2. Feigning attention

• give your full attention. clients pick up when you are ‘faking it’

3. Avoiding difficult material

• this is often the heart of the matter for the client

4. Allowing distractions

• be present with the client. Phones, emails etc. can be addressed at a later date.


Habits to Avoid

5. Finding fault with the speaker

• Be compassionate in your dealings with clients

6. Becoming overstimulated by something the speaker says

• Withhold evaluation until comprehension is complete - hear the speaker out

7. Wasting the advantage of thought-speech speed

• Speaking 100 words per min (WPM), thought 500 wpm. Don’t use the difference to float off on tangents or plan your meal for dinner. Use it to really listen to everything the client is saying and not saying, between the lines etc.


Habits to Avoid

8. Allowing emotion-laden words to arouse personal antagonism

• Compassion and non-judgment are key to building therapeutic relationships.

9. Listening only for details or facts

• The story come from the whole person, not just the facts

10.Using medical jargon as this widens the gap for the clients understanding of illness


Asking the right questions


Professional Questioning Skills

o During the process of developing a trusting,

collaborative relationship with your client you

start to become more confident in the skilled

use of professional and sensitive questions.

o As with attending, following and reflecting,

good use of questioning can encourage

clients to communicate their needs better.


Professional Questioning Skills

Skilled use of questions:

1. Provide a framework to guide/direct the session

2. Allow the session to flow well and move along to the

benefit of both the client and the practitioner – keep it

on track

3. Open up new areas for discussion

4. Assist in focussing and clarifying client concerns

5. Support client self-exploration, bringing out additional

specifics

6. Helps the practitioner more fully understand the

issues at hand

(Ivey & Ivey, 2007)


Initial Question

o Initial Question(s):

• If possible you want the client to describe their

presenting problem(s) in their own words.

• Encourage them to be as descriptive as possible.

• Open ended questions are a good way to allow the

client the time and space to ‘present’ their

problems.

o Examples include:

• "What brings your here? How can I help you? What

seems to be the problem?“

(Goldberg, A Practical Guide to Clinical Medicine)


Open & Closed Questions

o Closed questions – can be answered in a

single word or a short phrase e.g.

• Do you experience anxiety?

• Do you go to the toilet daily?

What are the advantages and disadvantages of

closed questions?



o Open questions – are likely to receive

extended, more detailed answers.

o They start with what, why, how, describe.

• How have you been after your operation?

• What do you think is keeping you awake at night?

What are the advantages of open questions?



o Open questions disadvantages:

• Individual clients give varying degrees of detail

• Responses may lack relevance or be buried in

useless detail

• Questions may be too general or allow clients to go

off track too easily

• Extended answers can take time.


Follow up questions

o There is no ideal way to question clients

however there are ways of encouraging client

responses/openness.

Read page 32 Verbal Responses – Assisting the

Narrative, and page 33 Examiner’s Verbal

Responses of the Reading- Verbal Responses

from Physical Examination & Health

Assessment, 7th ed, Jarvis.


Sensitive & Proactive Questioning

Skillso Questions have a down side as well and can

easily be abused in the interview process.

o Some issues include:

• Bombarding/ grilling/ interrogating the client – too

many questions at once

• Multiple questions – does not allow to fully express

themselves or finish each question appropriately

• Questions as statements e.g. ‘Don’t you think that

doing more exercise would be good for you?’


Sensitive & Proactive Questioning

Skillso Why questions can be used inappropriately

e.g. ‘Why did you eat that if you knew it was

not good for you?’

o Using questions to overly control the session

and the content – can be used intrusively and

for the practitioner’s gain or curiosity rather

than furthering the interview.

(Ivey & Ivey, 2007)


The Art of Questioning

Clarification:

• Check back with the client to ensure

understanding or to check a specific detail

• If client says something that was unfamiliar

to you – CLARIFY

• e.g. the client names a condition that you

are not familiar with



Encouragement for client to talk openly:

o You may have asked a personal question

which is of a sensitive nature to the client –

the client starts to answer, but stops talking:

o Encourage by letting them know they can

continue or asking about the specific issue

e.g. “You mentioned that the problem started

due to a ‘bad lifestyle” in your early 20’s, can

you tell me more about that”



Digressing/Avoiding Answer:

o The client does not seem to answer your question directly. May be a sign that they are concealing something or are embarrassed to answer.

• E.g. How many alcoholic drinks do you have on a weekly basis?

• Ans: Oh, I’m not quite sure – maybe 2 or 4

o Invite the client to answer in more detail if it is pertinent to the presenting complaint



o Going in circles:

o Client seems to being repeating the same

thing over and over.

o Summarise what the client has repeatedly

said and move on to the next question.



o Check your understanding:

• The client has mentioned something that their

doctor has told them about a side effect of their

medication. You did not quite understand:

• So, the medication you are taking at present may

be contributing to how you are feeling?

o Check Client understanding:

• Throughout the consultation, ask the client if there

is anything they wish to ask YOU!!


Questioning and Diversity

o Western style questioning can be experienced

as intrusive or rude for people from other

cultures.

o For example, people from Aboriginal

communities and from other, usually

collective, communities can sometimes

experience a breach of trust by insensitively

and unskilled questioning.

(Ivey & Ivey, 2007)



o Sometimes people from a range of diverse

backgrounds such as gay, lesbian or

transgender may already feel ‘under the

societal microscope’ and may experience

unskilled use of questions as invasive or more

about the practitioner than about them

(Ivey & Ivey, 2007)



o In summary, be sensitive always to the

individual you have in front of you at any point

and be aware that each person will respond

differently to questioning.

(Ivey & Ivey, 2007)


Asking the Right Questions

Unfamiliar phrases

The client has used an unfamiliar phase.

"Could you explain what you think the doctor

meant by saying 'there's been hiccup' with your

condition?"

Encourage without bias

The client is getting into sensitive areas and

has stopped talking. You want to encourage

without bias or prejudice

"You say things started to fall apart when you

started drinking heavily".

Digressing

The client is digressing and is not answering

your question directly.

"Perhaps I'm mistaken, but weren't you going to

tell me about what you did the last time you felt

this type of discomfort?”

Going in circles

The client has been going in circles, saying

the same things over and over. You want to

move on.

“Let me summarise what I understood you to say.

You said…Now was there anything else effecting

your problem”

Clarification

The client has just said something that does

not seem to agree with a statement made

earlier. You want to clarify

"I thought you said earlier that ... Now I hear you

saying …Would you mind going over that for me

please so that I get it right in my mind".


Asking the Right QuestionsChecking Understanding

The client has stated an opinion,

and you want to check your

understanding.

"In your opinion the prescribed

medication from your doctor has not

been working as well as you

expected?"

Drawing out reservations

You feel that the client is bothered

by something you said.

"Something seems to be bothering

you about what I just said. Will you tell

me what it is?"

Checking for specifics

Your client has made a general

statement about previous treatment

or diagnosis.

"What specifically do you think

happened on that occasion?" or "Was

it your doctor who told you that you

had high blood sugar?"

Determining priorities

It seems to be a complex case, and

you need to ascertain exactly what

the client expects/wants today, and

the longer term.

"Of all your problems you have told

me, what would you prefer to be

attended to first?" or "What is

important to you when it comes to

your health?"


Asking the Right Questions

Obtaining feedback

You have stated some strategies

for change and want some

feedback from your client.

"How do you think these changes

will benefit you in the long term?"

Focusing

You have outlined several

suggestions and you want to

focus attention on them.

"Out of those suggestions I have

outlined which do you think will be

the easiest for you to follow?"

Controlling the time

Although you should allow the

client to talk freely about issues,

you need to ensure that you

control time management

"As we only have a few minutes

remaining before we talk to our

supervisor, do you mind if I can now

take your blood pressure?"


Avoiding the Wrong QuestionsAvoid asking yes/no questions

Not "Is your arthritis very painful?"

But "Tell me about your arthritis …"

Avoid asking multiple choice questions

Not "Is the pain dull, throbbing, or …?"

But "Describe the pain."

Avoid putting your words into the client's

mouth

Not "Do you eat oily fish 2 or 3 times a

week?"

But "Tell me about your diet."… "Any

fish?" … "What type?" … "How often?"

Avoid making presumptions

Not "That must have been very distressing

for you."

But "How did your feel about that?"

Avoid being apologetic, but remain sensitive

Not "Would you mind terribly if I asked you

about your libido?"

But "Libido can be a good measure of

health. How has your libido been recently?"

Avoid being overly empathetic

Not "Oh, I had that! I know exactly what

you are going through"

But "I can only guess what you are going

through. Tell me all about it."


Helpful TechniquesUse continuation phrases "And then …?" or "What happened next?"

or even just an empathetic murmur or an

encouraging nod of the head may be

enough for the client to continue.

Reflect what has just been said,

summarizing.

"So, after your daughter left home, and

you broke your hip, your husband starting

drinking heavily …"

Try to get the client's own idea of the cause

of the dis-ease

Why do you suppose you get so angry at

those times?"

or "Do have any idea why you have

psoriasis?"

Explore feelings (if appropriate - remember

you are not a trained counsellor)

"When you finally got the diagnosis, how

did you feel?"

Final check before moving on. "Is there anything more you can tell me

about your kidney condition?"

Move on, eliciting more symptoms or

concerns.

"Anything else?"


Avoid Prescription

"How much water do you drink a day?"

"Oh, about two glasses."

Not "Well, you know you should drink

eight glasses of water a day, don't

you?"

…

…

But "If you were asked to increase

your water intake, how much more do

you think you could manage?"

Or Client: "So what foods are rich in

calcium?" Practitioner: "Well, there

are almonds, …"

…

Practitioner: "Before you leave, I will

write a list for you to take with you."

Be Honest If you do not know the

answer to a direct question, admit it.

Your client will quickly determine if

you are being deceptive, but will

respect you for your honesty. You can

learn so much from your client!

"That's very interesting. I would need

to go back to my notes on Paget's

Disease. Would you care to remind

me about its symptoms?


Traps of Interviewing

Read page 35 of Physical Examination & Health

Assessment, 6th ed:

Ten Traps of Interviewing

In pairs, discuss if there are any of the 10 ‘traps’

you identify with and ways you can overcome

these traps.


Prioritising information


o Document the most important presenting complaint or

acute problem first!

o Recognising symptoms/responses that demand an

urgent assessment as compared to those that are of

lower priority will come with time and experience.

o Give all client complaints careful consideration as they

may be markers of something more serious or

underlying.

o Some, however, will become "a something" (a

recognizable clinical entity) or "a nothing".

(Goldberg, A Practical Guide to Clinical Medicine)

Prioritising


Prioritising

o When determining the first problem, consider:

• Acuity – is the condition short or long standing?

Does it need immediate consideration?

• Severity – does the condition have serious health

implications or is it life threatening?

• Reason for consult/referral – an assessment,

treatment plan, to talk over possible treatment

options, practitioner or ideas shopping

• Scope of practice – are you qualified or

experienced enough to treat the client's condition,

do you feel confident to do so?


Prioritising

o When determining the first problem, consider:

• New/previously unidentified problems – has a

potentially serious problem emerged during

questioning or between consults?

• Worsening of previously identified problem

• Ability to resolve the problem (vitality) – is the client

vital enough to heal/recover from a problem, will a

problem need ongoing management, medical or

otherwise

• Remainder of problems addressed in descending

order


Case Study

o Read HMCL211_SN11_Case Study and

answer the following questions:

o How would you prioritise John’s issues?

• Go through the priority considerations with each of

John’s presenting complaints and any elicited

complaints.

• Would you refer John for further assessment or

care? If so, in pairs write a letter of referral to the

practitioner of choice outlining why you have

referred him. Include all pertinent case details. Use

the Template Referral Letter from the Hub.


References

o Goldberg C, A Practical Guide to Clinical Medicine,

<http://meded.ucsd.edu/clinicalmed/history.htm>, viewed 26th November

2014

o Holle, L, Salvo, M, 2014, SOAP Note Lecture, archive.saber.wijiti.net,

viewed 26th November 2014

o Ivey A.E & Ivey M.B, 2007, Intentional Interviewing and Counselling,

Thomson Brooks/ Cole: California

o Jarvis, C 2012, Physical examination & health assessment, 6th edn,

Elsevier Saunders, St Louis, MO.

http://meded.ucsd.edu/clinicalmed/history.htm


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Documents

Session 11 Clinical Skills 1 · · 2016-09-06Session 11 Clinical Skills 1 ... • Subjective vs Objective information (S vs OAP, ... • e.g. client reports or suspects gluten intolerance