Discussion Unit 2: The interview
Iosif Padurets posted Jun 14, 2018 11:48 PM
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- What does it means to document accurately and appropriately?
It means that providerâ€™s documentation has to reflect all necessary details of the interview that are within scope of providerâ€™s practice and meet clinical and legal requirements.
- What are the documenting guidelines? When is it appropriate to use abbreviations?
Documenting guidelines are usually specified by organizational standard of practice. All documentation must be dated and completed at the time of service. At the same time, least common abbreviations are discouraged of use because it creates a potential for errors, miscommunication and possible safety concerns (Kaiser Permanente, 2018).
- What is the difference between subjective and objective data?
Subjective data are variables that described by patient vs objective data is data that is collected by provider during examination/assessment.
- What does it mean to demonstrate clinical reasoning skills?
Demonstration of clinical reasoning is application of learned material by the provider in the clinical settings.
- How can you use clinical reasoning to plan the organization of a comprehensive exam?
Clinical reasoning may be a factor in focused assessment and organization of comprehensive exam. For example, patient comes with chief complain: headache. In this case provider can structure his/her exam and interview around the topic, causes, history, and other relevant information that will help in obtaining the data related to the chief complain.
- How will you document variations of normal and abnormal assessment findings?
Documentation of normal and abnormal assessment findings are documented according to acceptable limits that define the ranges. At the same time, each normal or abnormal finding is documented in very descriptive manner with details or example of findings.
- What factors influence appropriate tools and tests necessary for a comprehensive assessment?
It depends on focus of assessment. Furthermore, application of evidence-based practice may influence use of appropriate tools in obtaining accurate data that is required for deriving diagnosis or tailoring treatment plan (Budd et al., 2018).
- Reflect on personal strengths, limitations, beliefs, prejudices, and values.
As any other individual I have my strengths or limitations. However, generally I am open-minded when it comes to any topics. I am willing to listen others point of view and try to obtain data that I could use to derive my stance on a topic.
- How will these impact your ability to collect a comprehensive health history?
Any information that is obtained during comprehensive health history may contribute to patient plan of care. In order to improve ability to collect data and to improve comprehensive health history I was always attempted to be present during patient assessment by the provider. It was interesting to observe how each provider assessed patient and performed their exam. It showed different variations and approach in diagnosing chief complain.
How can you develop strong communication skills?
Any skills are mastered with practice and repetition and constructive criticism.
- What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?
Focused interview with open-ended questions may help patient to be open to discuss more information about their health.
- What relevant follow-up questions will you use to evaluate patient condition?
It is application of closed loop communication. I mean, to follow up on the care plan and obtain patients feedback.
- How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?
It requires for provider to be culturally competent in order to be on a same page as patient and to demonstrate understanding/empathy in patient care (McElfish et al., 2017)..
- What opportunities will you take to educate the patient?
Education opportunities come very often in a clinical settings. For example, these opportunities come up during comprehensive assessment, when creating care plan and so on.
Budd, E. L., deRuyter, A. J., Zhaoxin, W., Sung-Chan, P., Xiangji, Y., Furtado, K. S., & … Mui,
T. (2018). A qualitative exploration of contextual factors that influence dissemination and implementation of evidence-based chronic disease prevention across four countries. BMC Health Services Research, 18(1), 1-13.
Kaiser Permanente (2018). Medical Records and Documentation
Standards. Retrieved fromhttps://provider.ghc.org/open/render.jhtml?item=/o…
McElfish, P. A., Long, C. R., Rowland, B., Moore, S., Wilmoth, R., & Ayers, B. (2017).
Improving Culturally Appropriate Care Using a Community-Based Participatory Research Approach: Evaluation of a Multicomponent Cultural Competency Training Program, Arkansas, 2015-2016. Preventing Chronic Disease, 14E62.