Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University.
-
Upload
annis-stanley -
Category
Documents
-
view
215 -
download
2
Transcript of Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University.
Section II Inquisition
Dr. Zhuoren Lu
First Hospital
Xian Jiaotong University
The completeness and accuracy of the information collected by inquisition will contribute to the proper diagnosis, management and treatment of the patient’s problem.
Two major components of medical interviews:
content
technique
Content of the interview
introduction chief complaint history of the present illness past medical history review of systems personal history family history closure
Technique: interview skills Organization Timeline Transitional Statements Pacing of interview Questioning Skill-Type of Question Questioning Skill-Duplication Questioning Skill-Summarizing Questioning Skills-Lack of Medical Terms Questioning Skill-Documentation Rapport-Facilitative Behavior
Appearance and Courtesy Rapport-Facilitative Behavior Rapport-Positive Verbal Reinforcement Patient’s Perspective Impact on Patient and Family and Self Image Support system Patient’s Expectation Patient’s Understanding Admitting Lack of Experience Rapport-Encouragement of Question Closure of the interview
Five basic elements: AEIOU Audition: to listen to your patient cordially and
carefully. Evaluation: to judge the relevance of data you
obtained and importance to the patient’s problem. Inquiry: to obtain complete information, and
clarify and document this information. Observation: to watch the patient’s expression, Understanding: to understand the patient’s major
concern, elicit the patient’s perspective on his illness and explore the patient’s expectation regarding diagnosis and treatment.
Outline of Case Record
1. Biographical data
2. Chief complaint:
3. History of present illness
4. Past history
5. Review of system
6. Personal history
7. Marital history
8. Menstrual history
9. Childbearing (reproductive) history
10. Family history
11. Physical examination
12. Laboratory tests and instrumental examination
13. Summary
14. Primary diagnosis