6512-Midterm-Review-Nov 2021graded A
Building A Complete Health History
1. Communication techniques used to obtain a patient’s health history
o Courtesy
▪ Knock before entering a room
▪ Address (first time) the patient formerly, such as Miss, Ms., Mrs. Mr.
– can shake their hand(s)
• Ask how they want to be addressed
• Ask pronouns
▪ Meet and acknowledge others in the room. Establish their role and degree
of participation
• HIPAA – ask is it ok to…
• Ask if there are others that they want present
• Learn their names
▪ Ensure confidentiality
▪ Give them your undivided attention – take some time – don’t rush out
• Stance (sitting or standing, in the room vs in the doorway etc)
▪ Take minimal notes – use keywords. Observe and listen
• Eye contact if culturally appropriate
▪ Respect the need for modesty
▪ Allow the patient time to change back into street clothes before resuming
conversation
•
o Comfort
▪ Ensure everyone is comfortable (including yourself)
▪ Maintain close, but comfortable proximity with patient
▪ Maintain privacy. Pull curtains and shades as applicable
▪ Ensure comfortable room temperature. Provide blanket if needed
▪ Ensure good lighting
▪ Ensure quiet surrounding
▪ Pace interview. If necessary, prioritize and complete at another visit
,6512-Midterm-Review-Nov 2021graded A
• Allow time for answers
o Connection
▪ Look at patient, maintain good eye contact (if culture allows)
▪ Watch your language (don’t use technical jargon & don’t patronize)
• Define as you go
• Educate as your go
▪ Don’t dominate the discussion (listen closely & allow patient to
prioritize issues)
• Allow time for them to process and respond
▪ Keep an open mind – don’t accept previous diagnosis as a chief complaint
• Keep an open but always questioning approach
▪ Inquire if patient turned away from another provider to come to you
▪ Take history and complete physical exam before looking at previous tests
• Consider first what the patient has to say
▪ Avoid leading or direct questions in the beginning
• Use open-ended questions – with time for response
o Follow-up with closed questions to clarify.
• Let the specifics evolve
▪ Avoid being judgmental
▪ Respect silence – pauses can be productive
▪ Be flexible
▪ Assess the patient’s potential as a partner in their care
• And family or supporting friends
▪ Seek clues to problems from patient’s verbal behavior and body
language (talking too fast or too little)
▪ Look for hidden concerns underlying chief concern
▪ Never trivialize any finding or clue
▪ Problems can have multiple causes – do not leap to one cause too quickly
▪ Define any concern completely: LOCATES, OLDCARTS
• OLDCARTS – use in HPI
,6512-Midterm-Review-Nov 2021graded A
o Onset, location, duration, character, aggravating
factors, reliving factors, time and severity
• LOCATES – used in HPI
o Location, onset, character, associated signs and
symptoms, timing, exacerbating/relieving, severity
o Confirmation (speak back/read back)
▪ Ask patient to summarize the discussion (should be a clear understanding)
▪ Allow the possibility of more discussion with another open-ended
question (“Anything else you would like to bring up?”)
▪ If there is a question that you cannot immediately answer – say so &
follow up later if possible
▪ If you have made a mistake, make every effort to repair it.
• Candor is important for the development of a trusting partnership.
▪ Most patients respect it.
2. Recording and documenting patient information
o Illustrations – sometimes can be a better description
o POMR – problem oriented medical record
▪ Comprehensive health history
• Chronological order
• HPI - OLDCARTS
▪ Complete physical examination
▪ Problem list
▪ Assessment/plan
▪ Baseline & problem directed labs/radiology
▪ Progress notes
3. SOAP note documentation
o Subjective data
▪ Told to you by patient
o Objective data
▪ What you see
o Assessment
▪ Interpretations/conclusion – rational
▪ Diagnostic strategy
▪ Present and anticipated problems
▪ Ongoing and future care
o Plan
▪ What you intend to do
▪ Specific for each problem
▪ Includes: diagnostics/therapeutics/patient education
, 6512-Midterm-Review-Nov 2021graded A
4. Subjective vs objective information when documenting
o Subjective – information from the individual’s point of view (symptoms);
may include feelings, perceptions, and concerns
o Objective – observable and measurable information obtained through
observation, physical examination, and laboratory and diagnostic testing
5. Ethical decision making and beneficence
o Beneficence – promoting/doing good
Diversity and Health Assessments
6. Cultural awareness and diversity
o Culture – reflects the whole of human behavior, including ideas and attitudes;
ways of relating to one another; manners of speaking; and the material products of
physical effort, ingenuity, and imagination
o Physical characteristics – gender, race, phenotypic traits
o Minimize stereotyping and prejudice to achieve cultural competence
o Cultural competence – Knowledge of cultural encounters, desire, awareness,
knowledge, and skill
o For ethnic minorities, assess social context through inquiry of stressors, support
networks, sense of life control, and literacy
o Be sensitive to a patient’s heritage, sexual orientation, socioeconomic
status, ethnicity, and cultural background
7. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations
o Disease is shaped by illness and illness is shaped by the totality of the
patient’s experience
o Definition of ill or sick is based on the patient’s belief system and is
determined by their enculturation
8. Functional assessments
o Beliefs and behaviors that will have an impact on patient assessment include:
▪ Mode of communication – speech, body language, space
• In the US, people talk more loudly while the English worry about
being overheard and are more modulated
• In US – people are direct in conversation and prefer to avoid the
subject and to come to the point quickly while the Japanese do the
opposite, using indirection and talking around points, and
emphasizing attitudes and feelings
• Silence allows those who are Native American to think and a
response should not be forced; allow for quiet time
• Firm eye contact is evident in the Spanish and French while
Asian and Middle Eastern cultures believe it is a sign of
disrespect.
Building A Complete Health History
1. Communication techniques used to obtain a patient’s health history
o Courtesy
▪ Knock before entering a room
▪ Address (first time) the patient formerly, such as Miss, Ms., Mrs. Mr.
– can shake their hand(s)
• Ask how they want to be addressed
• Ask pronouns
▪ Meet and acknowledge others in the room. Establish their role and degree
of participation
• HIPAA – ask is it ok to…
• Ask if there are others that they want present
• Learn their names
▪ Ensure confidentiality
▪ Give them your undivided attention – take some time – don’t rush out
• Stance (sitting or standing, in the room vs in the doorway etc)
▪ Take minimal notes – use keywords. Observe and listen
• Eye contact if culturally appropriate
▪ Respect the need for modesty
▪ Allow the patient time to change back into street clothes before resuming
conversation
•
o Comfort
▪ Ensure everyone is comfortable (including yourself)
▪ Maintain close, but comfortable proximity with patient
▪ Maintain privacy. Pull curtains and shades as applicable
▪ Ensure comfortable room temperature. Provide blanket if needed
▪ Ensure good lighting
▪ Ensure quiet surrounding
▪ Pace interview. If necessary, prioritize and complete at another visit
,6512-Midterm-Review-Nov 2021graded A
• Allow time for answers
o Connection
▪ Look at patient, maintain good eye contact (if culture allows)
▪ Watch your language (don’t use technical jargon & don’t patronize)
• Define as you go
• Educate as your go
▪ Don’t dominate the discussion (listen closely & allow patient to
prioritize issues)
• Allow time for them to process and respond
▪ Keep an open mind – don’t accept previous diagnosis as a chief complaint
• Keep an open but always questioning approach
▪ Inquire if patient turned away from another provider to come to you
▪ Take history and complete physical exam before looking at previous tests
• Consider first what the patient has to say
▪ Avoid leading or direct questions in the beginning
• Use open-ended questions – with time for response
o Follow-up with closed questions to clarify.
• Let the specifics evolve
▪ Avoid being judgmental
▪ Respect silence – pauses can be productive
▪ Be flexible
▪ Assess the patient’s potential as a partner in their care
• And family or supporting friends
▪ Seek clues to problems from patient’s verbal behavior and body
language (talking too fast or too little)
▪ Look for hidden concerns underlying chief concern
▪ Never trivialize any finding or clue
▪ Problems can have multiple causes – do not leap to one cause too quickly
▪ Define any concern completely: LOCATES, OLDCARTS
• OLDCARTS – use in HPI
,6512-Midterm-Review-Nov 2021graded A
o Onset, location, duration, character, aggravating
factors, reliving factors, time and severity
• LOCATES – used in HPI
o Location, onset, character, associated signs and
symptoms, timing, exacerbating/relieving, severity
o Confirmation (speak back/read back)
▪ Ask patient to summarize the discussion (should be a clear understanding)
▪ Allow the possibility of more discussion with another open-ended
question (“Anything else you would like to bring up?”)
▪ If there is a question that you cannot immediately answer – say so &
follow up later if possible
▪ If you have made a mistake, make every effort to repair it.
• Candor is important for the development of a trusting partnership.
▪ Most patients respect it.
2. Recording and documenting patient information
o Illustrations – sometimes can be a better description
o POMR – problem oriented medical record
▪ Comprehensive health history
• Chronological order
• HPI - OLDCARTS
▪ Complete physical examination
▪ Problem list
▪ Assessment/plan
▪ Baseline & problem directed labs/radiology
▪ Progress notes
3. SOAP note documentation
o Subjective data
▪ Told to you by patient
o Objective data
▪ What you see
o Assessment
▪ Interpretations/conclusion – rational
▪ Diagnostic strategy
▪ Present and anticipated problems
▪ Ongoing and future care
o Plan
▪ What you intend to do
▪ Specific for each problem
▪ Includes: diagnostics/therapeutics/patient education
, 6512-Midterm-Review-Nov 2021graded A
4. Subjective vs objective information when documenting
o Subjective – information from the individual’s point of view (symptoms);
may include feelings, perceptions, and concerns
o Objective – observable and measurable information obtained through
observation, physical examination, and laboratory and diagnostic testing
5. Ethical decision making and beneficence
o Beneficence – promoting/doing good
Diversity and Health Assessments
6. Cultural awareness and diversity
o Culture – reflects the whole of human behavior, including ideas and attitudes;
ways of relating to one another; manners of speaking; and the material products of
physical effort, ingenuity, and imagination
o Physical characteristics – gender, race, phenotypic traits
o Minimize stereotyping and prejudice to achieve cultural competence
o Cultural competence – Knowledge of cultural encounters, desire, awareness,
knowledge, and skill
o For ethnic minorities, assess social context through inquiry of stressors, support
networks, sense of life control, and literacy
o Be sensitive to a patient’s heritage, sexual orientation, socioeconomic
status, ethnicity, and cultural background
7. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations
o Disease is shaped by illness and illness is shaped by the totality of the
patient’s experience
o Definition of ill or sick is based on the patient’s belief system and is
determined by their enculturation
8. Functional assessments
o Beliefs and behaviors that will have an impact on patient assessment include:
▪ Mode of communication – speech, body language, space
• In the US, people talk more loudly while the English worry about
being overheard and are more modulated
• In US – people are direct in conversation and prefer to avoid the
subject and to come to the point quickly while the Japanese do the
opposite, using indirection and talking around points, and
emphasizing attitudes and feelings
• Silence allows those who are Native American to think and a
response should not be forced; allow for quiet time
• Firm eye contact is evident in the Spanish and French while
Asian and Middle Eastern cultures believe it is a sign of
disrespect.
