Nursing History Taking

and Interviewing

20.2.2017 1
 OBJECTIVES
1. Describe the five steps of the nursing process and how it
applies to health assessment.
2. Describe an environment suitable for conducting an
interview and physical assessment.
3. Recognize personal perceptions and behaviors that facilitate
or hinder the interviewing process
4. Define effective interviewing techniques
5. Identify the components of the complete health history.
6. Describe how to assess the characteristics of a chief
complaint
20.2.2017 2
20.2.2017 3
 The Purposes of History Taking

 To identify the relevant organ system (s) responsible for

symptoms.
 To clarify the nature of the pathological processes at play
 To characterize the social context of patients’ illness,
their concerns, their interpretation of sypmtoms, beliefs and
attributions and any limitations of daily activities
consequent upon their illness.

20.2.2017 4
 History Taking
 Directs the focus of the physical exam
 Often the basis for the differentail diagnosis
 Keys:

 Trust
 Right questions
 Interpreting the responses
 Knowing what to do next
 Care begins simultaneously
20.2.2017 5
The Interview The Interview
• Subjective data
• Results of a successful interview
• The interview as a contract between patient
and examiner
◦ Time and place
◦ Introduction and explanation
◦ Purpose
◦ Length
◦ Expectations
◦ Confidentiality

20.2.2017 6
The Interview
Process of Communication

• Sending

• Sending
• Receiving

20.2.2017 7
 Process of Communication
• Internal factors
 Liking others
 Empathy
 Ability to listen
• External factors
Ensure privacy
Refuse interruptions
Physical environment
Dress
Note-taking
Tape and video recording
20.2.2017 8
20.2.2017 9
20.2.2017 10
20.2.2017 11
 Establish Rapport
• Get organized

• Introduce yourself in a warm, friendly manner

• Do not rely on memory

• Plan enough time

• Ensure privacy

• Maintain good eye contact

• Get focused/Listen attentively

• Be calm, confident, warm, and helpful

20.2.2017 12
 Begin the Interview

• Give your name and position

• Verify the patient’s name

• Briefly explain your purpose

20.2.2017 13
The Interview
Techniques of Communication-I

• Introducing the interview

• Working phase
– Open-ended questions
– Closed or direct questions

20.2.2017 14
20.2.2017 15
The Interview
Techniques of Communication-II

• Introducing the interview • Responses—assisting

• Working phase the narrative
– Open-ended questions – Facilitation
– Closed or direct – Silence
questions – Reflection
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary
20.2.2017 16
 Techniques of Communication-III
• Introducing the interview • Responses—assisting
• Working phase the narrative
– Open-ended questions – Facilitation
– Closed or direct – Silence
questions – Reflection
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary

20.2.2017 17
 Listen!!!! but How ?
• Be an empathetic listener
• Use short supplementary phrases
• Listen for feelings as well as words
• Let the person know when you see body language that
conflicts with what they say
• Be patient if the patient has a memory block
• Avoid the impulse to interrupt
• Allow for pauses

20.2.2017 18
 Observe, HOW?

• Carefully assess areas connected to verbal

cues
• Use your senses
• Note general appearance
• Observe body language
• Notice interaction patterns

20.2.2017 19
The Interview
Techniques of Communication-IV
• Responses—assisting
• Introducing the interview
the narrative
• Working phase
– Facilitation
– Open-ended questions
– Silence
– Closed or direct
– Reflection
questions
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary
20.2.2017 20
 Techniques of Communication-V
• Introducing the interview • Responses—assisting
• Working phase the narrative
– Open-ended questions – Facilitation
– Closed or direct questions – Silence
– Reflection
– Empathy
– Clarification
– Confrontation
– Interpretation
– Explanation
– Summary

20.2.2017 21
 How to ask Questions?

 Ask about the main problem first = chief complaint

 Focus your questions to gain specific information

about the signs and symptoms

 Don’t lead the witness

 Restate the other person’s words to clarify

 Use open-ended questions

 Avoid closed –ended questions , yes or no questions

20.2.2017 22
The Interview Techniques of Communication-VI
Ten Traps of Interviewing
1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions

20.2.2017 23
The Interview
Techniques of Communication-VII

• Nonverbal skills
– Physical appearance
– Posture
– Gestures
– Facial expression
– Eye contact
– Voice
– Touch
• Closing the interview

20.2.2017 24
The Interview
Interviewing People With Special Needs

 Hearing-impaired people
 Acutely ill people
 People under the influence of street drugs or alcohol
 Personal questions
 Sexually aggressive people
 Crying
 Anger
 Threat of violence
 Anxiety
20.2.2017 25
The Interview

Cross-Cultural Communication

• Cultural perspectives on professional

interactions
• Etiquette
• Space and distance
• Cultural considerations on gender and sexual
orientation

20.2.2017 26
The Interview
Overcoming Communication Barriers

• Working with (and without) an interpreter

• Nonverbal cross-cultural communication
– Vocal cues (and silence)
– Action cues
– Object cues
– Use of personal and territorial space
– Touch

20.2.2017 27
20.2.2017 28
20.2.2017 29
 Translation
Software /
Applications

20.2.2017 30
 Observations

• Body language

Argyle, using video tapes shown to the

subjects, analyzed the communication of
submissive/dominant attitude and found that
non-verbal cues had 4.3 times the effect
of verbal cues.
Argyle, M, Salter, V., Nicholson, H.,W illiams, M. & Burgess, P. (1970): The
communication of inferior and superior attitudes by verbal and non-verbal signals.
British Journal of Social and Clinical Psychology 9: 222-231.

20.2.2017 31
Observations • Body language

20.2.2017 32
 PLEASE USE THE
PEDESTRİAN
UNDERPASS

It's not what you say, it's how you say it.
 Observations

Healthcare Provider Body Language

20.2.2017 34
 How to terminate the interview

• If the session has been long, give a warning

• As the person to summarize their primary concerns

• Ask if there are other areas to be discussed

• Offer yourself as a resource

• Explain routines and provide information about who

does what

• End on a positive note

20.2.2017 35
 Charting & Documentation
• If it isn’t written, then it wasn’t done
• Chart at the time it occurs – if possible
• Follow facility guidelines
• Is the information clear and logical?
• Is it true?
• Is it non - judgmental?
• Record all abnormals and normals

20.2.2017 36
 Charting guidelines
• Be precise
• Stick to the facts
• Sign your name after each entry
• SOAP format, SOCRATES – focuses on specific
problems
• Prioritize the client problems

20.2.2017 37
20.2.2017 38