5 - Intro to Assessment Flashcards
What are the steps to The Clinical Method?
7
Gather information (Referral, Hx, exam, etc.)
Evaluate patient’s subjective complaints and objective test results
Determine cluster of symptoms (syndrome)
Look for correlations among symptoms or underlying physical and mental processes
If syndrome exists, what is the prognosis
Use information (Hx, exam, life situation) to determine daily life impact
Use all information to estimate potential effect of treatment
What can be found in a patient’s Medical Record?
8
Patient Identification
Doctor’s Orders
Personal History
Medical History
Physical and Neurologic Exam
Specialists Consultations
Progress Notes
Lab Results/Imaging Results
What should you do before the patient interview?
Do Your Homework (read chart, medical history, exam reports, etc.)
Where should you conduct a patient interview?
In a Quiet Place free from Distractions
How should you initially approach the patient?
Tell the Patient Who You Are and Why You are Here
How should you interact with the patient during the interview?
(8)
Make the Patient Comfortable
Sit Down
Elicit the Patient’s Story
Be a Patient, Concerned, and Understanding Listener
Talk to the Patient at the Patient’s Level
Treat the Patient as an Adult Who Merits Respect
Prepare the Patient for What Comes Next
Reassure the Patient
Should Family Members/Significant Others be included in the patient Interview?
Yes (unless patient expresses otherwise)
Why is Interviewing central to role of diagnostician?
3
Gathers data about the individual
Transmits information
Establishes and maintains a working relationship
Interviewing serves as a _______ and a _______.
Tool
Relationship
Mastery of interviewing is typically excluded from required ______ and ________ experience.
Coursework
Practicum
What four things can be accomplished in a patient interview?
Vehicle for giving information
Means of establishing + sustaining a relationship
Tool for gathering data
Medium of therapy
Some clinicians consider interviewing a __________.
Secondary process
What are three downfalls of Case History forms?
Questions are generic
Questions may be threatening or engender guilt
Answering questions in one particular way, may prevent developing alternative answers
What exactly is the interview process?
Verbal and non-verbal exchange between professional and client
Is the interview an ordinary conversation?
No
What must the clinician and client become?
Co-workers
What do we need to consider when interviewing patients?
6
Multicultural considerations
Our own fears (you are a fraud, etc.)
Our own memory failure (learn to write things down)
Emotional barriers
Language gap
What is your specific purpose? (at least act like you have a purpose)
What is the 1st Goal when Interviewing?
Obtaining Information
How do we obtain information during an interview?
4
Setting the tone
Asking questions
Learn the presenting story
Pay attention to nonverbal messages
How do we set the tone during an interview?
4
(Think of interview as role-playing situation)
Select relaxed site
Convey sincere interest
Build rapport
Mutual trust and respect (client should feel like you know the answer)
How should we ask questions during an interview?
5
Use interview guide if possible
Discover how patient sees the problem
Discover when the communication disorder arose and under what conditions
Discover how the communication disorder has changed since its onset
Discover the consequences of the problem
What is the patient’s Presenting Story?
What will most patients have done?
What should we do as patient tells their story?
Their purpose for seeking help
Many clients will have rehearsed the story
Let the story unravel
What should we look for in Nonverbal Messages?
6
Eye contact
Facial expressions
Eye gaze
Body movements and postural shifts
Hand movements
Pitch, loudness, vocal quality
What should we avoid in an interview?
6
Yes/no questions
Phrasing questions in a way that inhibits responses
Concentrating on physical symptoms to the exclusion of client’s feelings
Providing information to soon
Negativistic or moralistic responses
Trusting observations to memory (RECORD INFORMATION)
