What is the best way to obtain specific information about a patient when taking the medical history?

What is the best way to obtain specific information about a patient when taking the medical history?

Obtaining an Older Patient’s Medical History

1. General suggestions.
2. Elicit current concerns.
3. Ask questions.
4. Discuss medications with your older patients.
5. Gather information by asking about family history.
6. Ask about functional status.
7. Consider a patient’s life and social history.

When interviewing a patient what is the key to obtaining accurate information?

When interviewing a patient, what is the key to obtaining accurate information and what should you avoid? KEY : Ask Open Ended questions. What is the number one reason for the failure in a relationship?

When preparing a patient for a breast examination which of the following is the most appropriate position?

The feel part of the breast self-exam should be done while lying down, with a pillow propping up your head and your arm resting behind it. With the opposite hand, take the first three fingers — index, middle and ring fingers — and use them to press down around the breast and surrounding area using circular motions.

What categories of information would you need to include for a complete health history?

Determine the following:

• Biographical data. Source of history.
• Reason for seeking care and history of present health concern. Chief complaint.
• Past health history. Allergies (reaction)
• Family history.
• Functional assessment (including activities of daily living)
• Developmental tasks.
• Cultural assessment.

How do you collect a patient’s history?

Greet the patient by name and introduce yourself. Ask, “What brings you in today?” and get information about the presenting complaint. Collect past medical and surgical history, including any allergies and any medications they’re currently taking. Ask the patient about their family history.

How do you ask a patient about social history?

Environmental / Social Questions

1. What other health care professionals are currently helping care for you?
2. What are your average daily activities?
3. Any children?
4. Ethnic background?
5. Finances; home situation (location, suitability, help available, transportation)
6. What do you do for a living?
7. Any inherited diseases?

How do you make sure you have clearly and accurately understood an inquiry or request made of you?

Confirm Your Understanding By Repeating and Restating the Other Person’s Idea. Another way to be sure you’ve understood what the other person is saying is to repeat what you heard using your own words. Restating the other person’s idea is a great way to show that you were listening carefully.

How do you communicate effectively with patients?

Communicating Effectively with Patients

1. Assess your body language.
2. Make your interactions easier for them.
3. Show them the proper respect.
4. Have patience.
5. Monitor your mechanics.
6. Provide simple written instructions when necessary; use graphics where possible.
7. Give your patients ample time to respond or ask questions.

How should a nurse instruct a client to perform a self breast examination to most effectively cover the entire breast?

Breast self-exam

1. Use the pads of your fingers. Use the pads, not the very tips, of your three middle fingers for the exam.
2. Use different pressure levels. Your goal is to feel different depths of the breast by using different levels of pressure to feel all the breast tissue.
3. Take your time. Don’t rush.
4. Follow a pattern.

How do you instruct the patient if you assess the breast using palpation technique?

palpate breasts with both the flat of your hand and fingers. follow systematically, in a circular pattern around the nipple or along the radial lines (simulate a clock) or vertical segments and feel the entire breast, including the tail near the axilla. feel the areola and nipple.

What information should be collected from the patient?

The patient’s full name and address.

Name of the medical practice releasing the information.

Name of the individual or facility to receive the information.

Specific information to be released.

The purpose of or need for the information.

Method of release of the information.

What to look for in a patient’s medical history?

Be alert for information about the patient’s relationships with others, thoughts about family members or co-workers, typical responses to stress, and attitudes toward aging, illness, work, and death. This information may help you interpret the patient’s concerns and make appropriate recommendations. The social history is also crucial.

What do you need to know about the medical interview?

The medical interview provides two categories of information unavailable from any other source: what the patient says about the illness and how it is said. What the patient tells the physician provides the factual content of the medical history.

Where can I find information about my patient?

There are several sources, including MedicAlert Foundation International. Gather information by asking about family history The family history is valuable, in part because it gives you an opportunity to explore the patient’s experiences, perceptions, and attitudes regarding illness and death.

Is the written medical history the same as the clinical interview?

The content and organization of the written medical history is often confused with the process by which the clinician actually collects information during the interview. The written medical history is actually a journalistic endeavor in which the clinician edits and organizes the patient’s spontaneous report into a formal, organized presentation.