Transcript Interviewing & Documentation

Interviewing & Documentation
THE NURSING INTERVIEW
J. Carley MSN,MA, RN, CNE
Fall, 2009
Interviewing & Documentation
Unit 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
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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Time and place
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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◦
Time and place
Introduction and explanation
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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◦
◦
Time and place
Introduction and explanation
Purpose
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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◦
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Time and place
Introduction and explanation
Purpose
Length
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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Time and place
Introduction and explanation
Purpose
Length
Expectations
The Interview
The Interview
 Subjective data
 Results of a successful interview
 The interview as a contract between patient
and examiner
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Time and place
Introduction and explanation
Purpose
Length
Expectations
Confidentiality
The Interview
 Sending
Process of Communication
The Interview
 Sending
 Receiving
Process of Communication
The Interview
Process of Communication
 Sending
 Receiving
 Internal factors
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Liking others
Empathy
Ability to listen
The Interview
Process of Communication
 External factors
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Ensure privacy
Refuse interruptions
Physical environment
Dress
Note-taking
Tape and video recording
Slide 4-2
Establish Rapport
 Get organized
 Do not rely on memory
 Plan enough time
 Ensure privacy
 Get focused
 Be calm, confident, warm, and helpful
Begin the Interview
 Give your name and position
 Verify the client’s name
 Briefly explain your purpose
The Interview
Techniques of Communication
 Introducing the interview
 Working phase
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Open-ended questions
Closed or direct questions
The Interview
Techniques of Communication
 Introducing the interview
 Working phase
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Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase
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Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase
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Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase
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Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase


Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase


Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative
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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase


Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative









Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase


Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative









Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
The Interview
Techniques of Communication
 Introducing the interview
 Working phase


Open-ended questions
Closed or direct questions
 Responses—assisting
the narrative





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Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
How to listen
 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
How to ask Questions?
 Ask about the main problem first = chief
complaint
 Focus your questions to gain specific
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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
Observations
 Carefully assess areas connected to verbal cues
 Use your senses
 Note general appearance
 Observe body language
 Notice interaction patterns
Techniques of Communication
The Interview
Ten Traps of Interviewing
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Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using “why” questions
The Interview
Techniques of Communication
 Nonverbal skills
 Physical appearance
 Posture
 Gestures
 Facial expression
 Eye contact
 Voice
 Touch
 Closing the interview
Interviewing People With Special Needs
The Interview
 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
The Interview
Cross-Cultural Communication
 Cultural perspectives on professional interactions
 Etiquette
 Space and distance
 Cultural considerations on gender and sexual
orientation
Slide 4-7
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
Slide 4-8
Translation
Software /
Applications
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.
Observations
 Body language
Observations
 Body language
Observations
 Body Language
A)”Hmm…
How long did
they say block
2.0 lasts?”
Observations
 Body Language
2. “Power
Point could
be the
miracle
cure for
insomnia..”
Observations
 Body Language
Observations
 Body Language
Observations
 Body Language
Observations
 Body language
Observations
 Body language
Observations
 Body language
Observations
 Body language
Observations
 Body language
Observations
Healthcare Provider Body Language
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
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
Charting guidelines
 Be precise
 Stick to the facts
 Sign your name after each entry
 SOAP format – focuses on specific problems
 AIR, DAR, PIE, DIE formats – focus on nursing
interventions and client response
 Prioritize the client problems
Interviewing & Documentation
Unit 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