Transcript Therapeutic Communication

PHA 3785
Therapeutic Communication
and Health History
Debra A. Allan Danforth,
MS, ARNP, FAANP
FAMU College of Pharmacy
12/10
Legal and Ethical Issues
 Legal refers to action or inactions that
may be held accountable by law,
particularly criminally, and also civil
 Ethics moral principles or standards of
conduct, and may be held accountable
in civil court
Legal and Ethical Issues
 Autonomy
 Beneficence
 Nonmaleficence
 Utilitarianism
 Fairness and justice
 Deontologic imperatives
Privacy
 Refers to the individual and their affairs
(Ex. The right to be left alone)
 Person’s
name
 Invasion of privacy
 Breach of confidentiality
 Autonomy
History and Communication
What Is Assessment?
 A data collection process
 A continuous process
 Establishes a baseline
 A systematic process
 Identifies patients’ strengths and
limitations
 Involves collecting, validating, and
clustering data
Purpose of Assessment
 Collect pertinent patient health status
data
 Identify abnormal findings
 Identify patients’ strengths and coping
resources
 Pinpoint actual health problems
 Identify risk factors for health problems
Assessment Skills
Cognitive Skills
Assessment is a “thinking process”
 Inductive and deductive reasoning

Ex. Inductive: used when assessing a post-op patient
who state it hurts to take a deep breath


Piece together pertinent data
Ex Deductive: patient is admitted to hospital with CHF.
Will look for specific signs and symptoms as you
perform the assessment and determines patient’s
response to illness

Looking for specific clues to support
Clinical decision making
Assessment Skills
Problem solving
 Reflexive thinking
 Is automatic, without conscious deliberations and comes
with experience
 Trial and error
 Is hit or miss thinking-random, not systematic and
inefficient
 Scientific method
 Is a systematic, critical thinking approach to problem
solving
 Intuition
 Is a problem-solving method that develops through
experience
Assessment Skills
Psychomotor Skills
Assessment is a “doing” process
 Skills needed to perform the 4 techniques
of physical assessment




Inspection
Palpation
Percussion
Auscultation
Assessment Skills
 Interpersonal/Affective Skills
Assessment is a “feeling” process
 Affective skills needed to
develop caring, therapeutic
healthcare provider-patient
relationships
 Include
verbal and nonverbal
 Establish trust and mutual respect
Assessment Skills
Ethical Skills
Assessment is being responsible and
accountable




Responsible & accountable for practice
patient advocate
Respect patients’ rights
Assure confidentiality
Types of Assessment
 Comprehensive
 Ongoing/Partial
 Problem focused
 Emergency
Types of Data
 Subjective

Definition: Of, relating to, or designating a
symptom or condition perceived by the patient and
not by the examiner.
 Objective

Definition: Indicating a symptom or condition
perceived as a sign of disease by someone other
than the person affected.
Identify Subjective or Objective
 Headache
 BP 170/110
 Nausea
 Diaphoresis
 Equal pupil reaction
 Dizziness
 Slurred speech
 Numbness in left arm
Therapeutic Communication
Central Objectives of
Interacting with a patient
 To find out what is at the root of that
person’s concern
 To help them in doing something about
 What does a patient need?
 What is the patient worried about?
 What does the patient expect of you?
History and Physical
 The heart of the diagnosis and
treatment process
 Must be done in an orderly process
 Must also be sensitive to the “soft” cues
that are almost always there
Goals of Patient Interview
 Information discovery
 Providing information to the patient
 Negotiating with the patient regarding
treatment management
 Counseling regarding disease
prevention
Ineffectiveness of Most
Communication
 Most people do not communicate well
 Causes an interpersonal gap and
isolates people from each other
Communication Barriers
 A barrier to communication is something
that keeps meanings from meeting
 Without realizing, people typically inject
communication barriers over 90% of the
time when one or both parties has a
problem to be dealt with or a need to be
fulfilled
Why are they High-Risk
Responses?
 They block conversation
 Increase emotional distance between
people
 Thwart the other person’s problemsolving efficiency
Categories of Barriers
 The “Dirty Dozen” of barriers to
communication can be divided into
three major categories
 Judging
 Sending
Solutions
 Avoiding Other’s Concerns
Judging
 Criticizing
 Name-calling
 Diagnosing
Sending Solutions
 Ordering
 Threatening
 Moralizing
 Excessive/Inappropriate Questioning
 Advising
Avoiding the Other’s Concerns
 Diverting
 Logical Argument
 Reassuring
Listening: More Than Merely
Hearing
 Listening refers to a more complex
psychological procedure involving
interpreting and understanding the
significance of the sensory experience
Listening Skill Clusters
 Attending Skills
 A posture of
involvement
 Appropriate body
motion
 Eye contact
 Nondistracting
environment
Listening Skill Clusters
 Following Skills
 Door openers
 Minimal
encouragers
 Infrequent questions
 Attentive silence
Listening Skill Clusters
 Reflecting Skills
 Paraphrasing
 Reflecting feelings
 Reflecting meanings
 Summative
reflections
Paraphrasing
 Concise response
 Essence of content
 Listener’s own word
Reflecting Feelings
 Improve capacity to “hear” feelings
 Listening for feeling words
 Inferring feelings from the overall
content
 Observing body language
 “What would I be feeling?”
Reflecting Meanings
 “You feel…because”
 Validation of Data
 Using
technical terms
 Not allowing patient to finish answer
 Too many questions
 Failure to find out patient’s interpretation
Summative Reflections
 Brief restatement of main themes and
feelings speaker expressed
 Gives speaker feeling of movement in
exploring content and feeling
Interview –
Communication Techniques
 Open Ended Questions
 Informing
 Closed Questions
 Redirecting
 Affirmation/Facilitation
 Focusing
 Silence
 Sharing Perception
 Clarifying
 Identifying
 Restating
 Sequencing Events
 Active Listening
 Suggesting
 Reflection
 Presenting Reality
 Humor
 Summarizing
Open End Questions
 Advantages
 Elicits a response
 Effective in stimulating descriptive or comparative
responses
 Allows patient to disclose information when he/she
is ready
 Provides clues to alertness, level of mental
abilities, organization of thought through
vocabulary
 Rapport is strengthened
Open End Questions
 Disadvantages
 Response
not relevant
 Digress to avoid disturbing data
 Anxiety increased if not articulated
Closed Questions
 Advantages
 Requires no more
than 1-2 words
 Used more initial
interview
 Disadvantages
 Limits answers
Affirmation/Facilitation
 Acknowledge patient’s response
through verbal and nonverbal response
 Reassures you are listening
 Nodding, sitting up and leaning forward
are nonverbal ques
 Verbal cues
 “ah
ha”, “go on”, “tell me more”
Silence
 Silence allows patient to collect
thoughts before responding and help
prevent hasty responses
 More uncomfortable for interviewer than
interviewee
 Gives interviewer time to think and plan
response
 Focus on patient’s nonverbal behavior
Clarifying
 If unsure or confused what patient says,
rephrase
 “let’s
me see if I have this right”
 “ I’m not sure what you mean”
Restating
 Restating the main idea shows the patient
that you are listening, allows
acknowledgement of feelings, and
encourages further discussion
 Also helps to clarify and validate what your
patient has said and may help identify
teaching needs

“I take a water pill every day for my blood
pressure”


“I see you take Lasix for your blood pressure”
“NO, I take a water pill”
Active Listening
 Pay attention
 Eye contact
 Listen to what patient tell you both
verbally and nonverbally
 Conveys interest and acceptance
 Watch your own body language
Reflection
 Acknowledge patient’s feelings
 “I’m

afraid of having surgery”
“You’re afraid of having surgery?”
 Encourage further discussion
Humor
 Can be very therapeutic
 Reduces anxiety
 Helps to cope more effectively
 Puts things into perspective
 Decreases social distance
Informing
 Giving information helps the patient with
making decisions on their healthcare
 Teaching
pre-operatively how to do a
procedure post-operative like coughing and
deep breathing can help the patient in the
long run
Redirecting
 Helps to keep communication
goal-directed
 To get back on track
 “Getting
clinic…”
back to what brought you to the
Focusing
 Allows to hone in on a specific area
 Encourages further discussion
 “Do
you do SBE?”
 “Have you had a MMG?”
 “Do you do a testicular exam?”
Suggesting
 Presenting alternative ideas gives your
patient options
 Helpful if patient is having difficulty
verbalizing feelings
 Good teaching tool
 “I’ve

tried to lose weight and I can’t”
“Have you tried diet and exercise”
Summarizing
 Useful conclusion
 Allows patient to clarify any
misconceptions
 “let
me see if I have this correct”
Three Essentials for
Effective Communication
 Respect
 Genuineness
 Empathy
How to Demonstrate
Respect for Patient
 Introduce yourself clearly and explain your




role
Do not use patient’s first name during initial
interview without permission
Inquire about and arrange for patient comfort
before getting started and during
Warn patient when going to perform
something painful or unexpected
Respond to the patient that shows you have
heard what they have said
Genuineness
 Be open, honest, and sincere
 Can detect a less-than honest response or
inconsistencies between verbal and
nonverbal behavior
 The ability to be yourself in a relationship
despite your professional role

“introduce yourself as a nursing student,
pharmacy student, nurse practitioner, pharmacist,
etc.”
Empathy
 Sensitive and accurate understanding of
the person’s feeling while maintaining a
certain separateness from the individual
 Understanding the situation that
contributed to or “triggered” the feelings
 Communicating with the other in such a
way that the other feels accepted and
understood
Patient-Centered Clinical Method
 What does it mean to be patient-
centered?
 It
means much more than merely being
“nice” or “kind” or “compassionate” to the
patient.
Patient-Centered Clinical Method

Is an evidenced-based, conceptual method of
practice consisting of the following interactive
components:
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
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Exploring both the objective disease processes and the
patient’s subjective illness experience
Striving to understand the whole person and how the
illness impacts their life and how their life context
influences risks for and responses to disease
Finding common ground between the pharmacist
perspective and understanding and that of the patient as
it relates to the problem, treatment, and expectations
Patient-Centered Clinical Method
Shared decisions about how best to approach
the patient’s problem
 Finding opportunities to incorporate prevention
and health promotion into the process of care
 Recognizing that the patient-pharmacist
relationship is a powerful resource and
essential to the health and well-being of both
participants in the relationship

Relationship Building
 Introduce yourself and explain your role
 ie: Patricia Dee, 5th year pharmacist student
 Using polite forms of address
 ie: Mr., Mrs., Ms., Dr.
 Listening Attentively
 Establish eye contact
 Assume an attentive body posture
 Establish a comfortable spatial position and distance
 Minimize distracting behaviors like excessive note-taking or
reading and talking at the same time
 Use summary statement
Relationship Building Skills
 P - partnership
 E- empathy
 A- apology
 R- respect
 L- legitimation
 S- support
Partnership
 Partnership – explicit statement to the
patient indicating your willingness to
work together in an effort to accomplish
therapeutic goals
 If
you would like I’d be happy to review the
plan with you to see if any adjustments
need to be made.
Empathy
 Empathy – capacity to recognize a
patient’s feelings or emotional reactions
I
know it must be frustrating for you to be
on this diet and not see much progress.
Apology
 Apology – willingness and ability to
acknowledge to another person that you
may be in part responsible for a
negative outcome, discomfort, ill
feelings, etc.
 I’m
sorry if I gave you the impression that I
didn’t think you were trying to watch your
weight.
Respect
 Respect – willingness to consider
another person “worthy of regard”; show
respect for another person by being
non-judgmental and setting aside
personal feelings in order to be helpful
and caring
I
admire you for continuing to make the
effort.
Legitimation
 Legitimation – intervention that
explicitly communicates acceptance of
the patient’s affect or feelings
I
think most people would feel frustrated
and want to give up.
Support
 Support – explicit statement conveying
your willingness to be available to the
patient in a helping capacity
 Please
let me know if there is anything that
I can do.
Non-Verbal Communication
Non-verbal SOFTEN Skills: Listening is as important as
speaking and these non-verbal skills facilitate the
demonstration of active listening.
 S O F T-
 E N-
smile
open posture
forward lean
touch (caring, reassuring)
eye contact
nod
Health History
Practical Points for
History Taking
 Use a quiet, sympathetic but confident tone of
voice
 Make your questions simple and brief
 Allow plenty of time for patient to express or
explain, before you clarify or continue
 Clarify inconsistencies between sources or
interpretations in non-threatening or nonpersecuting manner
Practical Points for
History Taking
 Avoid asking patient for information that they
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

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are not likely to have as this can increase
anxiety or mistrust about unknown
Ask only appropriate questions
Use terminology appropriate to their social,
cultural and educational status
Use significant others, when present, to
clarify points that seem to be vague
If a child is distracting, provide attention
devices
Pitfalls
 Leading the patient
 People will tell you what you want to hear
 Do not lead the patient
 Let them tell you in their own words
 Biasing yourself
 Because of the patient, disease or health care
provider
 Letting family members answer for patient
 Need to let patient answer questions
Pitfalls
 Asking more than one question at a time
 Not allowing enough response time
 Using medical jargon
 Assuming rather than clarifying/validating
 Taking the patient’s response personally
 Feeling personally uncomfortable
Pitfalls
 Using clichés
 Offering false reassurance
 Asking persistent or probing questions
 Changing the subject
 Taking things literally
 Giving advise
 Jumping to conclusions
Pitfalls
 Data Collection
 Omission
of pertinent questions
 Omission of pertinent negatives
 Failure to elicit temporal relationships
precisely
 Failure to elicit follow-up important leads
Pitfalls
 Structure
 Beginning
too fast
 Allow patient to ramble
 Needless repetition of questions
 Poor transitions
 Covering delicate areas too early
Pitfalls
 Practitioner Attitude
 Acting
too friendly or not friendly enough
 Not listening

Lack of eye contact
 Not
enough interest or too much interest in
emotional factors
Phases of the Interview
 Introductory
 Is the time to introduce yourself to the patient,
purpose of the interview and the time frame
needed to complete
 Working
 Where data is collected, very structured, and the
longest phase.
 Need to listen what is said verbally/nonverbally
 Termination
 Need to summarize and restate findings
Components of the
Health History
 Identifying info
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Chief Complaint or Chief Concern (CC)
History of Present Illness (HPI)
Functional History (FxH)
Past medical history (PMH)
Family history (FH)
Personal and Social (SH)
Review of systems (ROS)
Biographical Data
 Name
 Religion
 Address
 Marital Status
 Phone Number
 Number of
 Social Security #
 Contact Person

 Age (Birth Date)

 Gender

 Race/Ethnicity


Dependents
Educational Level
Occupation
Insurance
Advance Directive
Reliability
Identifying Info
 Name
 Age (Birth Date)
 Gender
Chief Complaint/Concern
for Seeking Healthcare
What can the patient’s reasons for seeking
health care and the patient’s current
health status tell you?
Current Health Status/
Present Problem or Illness
 Primary Level
 Usual
state of health
 Any major health patterns
 Unusual patterns of health care
 Any health concerns
 Secondary and Tertiary
 Perform
a Symptom of Analysis (AOS)
Symptom Analysis
P = Precipitating / palliative factors
Q = Quality / quantity of symptom
R = Region / radiation / related
symptoms
S = Severity
T = Timing
Symptom Analysis
 O:
 L:
 D:
 C:
 A
 R:
 T:
 S:
Onset
Location
Duration
Character
Aggravating/Associate
Factors
Relieving Factors
Temporal Factors
Severity
 O:
 L:
 D:
 C:
 A:
 R:
 T:
 S:
Onset
Location
Duration
Character
Aggravating/Associate
Factors
Related symptoms
Treatment
Severity
Analysis of Symptoms
“Sacred 7”
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chief concern
Location-radiation
Quality
Quantity
Time
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Onset
Duration
Frequency
Progression over time
 Setting/Context
 Aggravating Factors
 Relieving Factors
 Associated Symptoms
 Similar symptoms in
past
 Explanation why
concern presented now
 Theories or worries
about causes /
implications
 Impact of symptoms
Functional Assessment
 Activity of Daily Living (ADL’s)
 Dressing, Grooming, Feeding, Bathing
 Instrumental Activities of Daily Living
(IADL’s)
 Driving,
Cooking, Using medication
 Advanced Activities of Daily Living
(AADL’s)
 Work,
Church, Recreations
Functional History
 ADLs; one’s basic personal care
 Listed in order of hardest to easiest to perform
 Minimum requirement to live home alone
 Represent primarily physical ability
 Acquired by the first time one leaves home (about 6
years old; off to kindergarten)
 IADLs; one’s ability to manage home life for them
self


Represent cognitive component in addition to physical
ability
Acquired by the second time one leaves home (about 16
years; off to college, career, etc.; the things mom and
dad won’t be doing now)
 AADLs; what makes life meaningful, not
necessarily essential for survival (as ADLs and
IADLs are)

Often correlate with quality of life measures
Past Medical History
 General Health and Strength
 Major Adult Illness
 Childhood Illness
 Menstrual Cycle (females
(Serious/chronic)
 Psychiatric conditions
 Medications
only)
 Depression
 Screenings
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Prescription
OTC
Alternatives
Allergies
Hospitalizations
Surgeries
Serious Injuries/Accidents
Transfusions

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Blood pressure
Diabetes
Cholesterol
Mammogram
Stool for occult blood
Colonoscopy
 Immunization
Family History
 Patient
 Siblings
 Grandparents
 Spouse/Significant
 Parents
other
 Children
Genogram
Personal and Social History
 Education
 Marital Status
 Home condition
 Occupation
 Military record
 Cost of Care
 Habits
 Tobacco
 Alcohol
 Recreational Drugs
 Exercise
 Sleep and Rest
 Domestic Violence
 Nutrition and diet
 Coffee, Tea
 Special Diet
 Living Will/ Healthcare
 Religious preference
 Sexual History
surrogate
 Cultural Requirement
Assessment of
Domestic Violence
 HITS (Sherin et al, 1998)
H
I
T
S
Hurt you physically?
Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?
Assessment of Exercise
 FIT acronym to ask about exercise
regimen
F
I
T
is for FREQUENCY of the activity
is for the INTENSITY of the activity
is for the TIMING, or duration, of the
activity
Assessment of
Substance Abuse
 Abuse of alcohol and other substances is a highly
prevalent problem
 Healthcare providers must assess for such behaviors
because of implications for complications of illness
 Two types of tools used to assess alcoholism

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CAGE
TACE
 The history of alcohol consumption and dependency
can further be assessed by using the questionnaires



HALT
BUMP
FATAL DT
CAGE
 C: Are you CONCERNED about your
drinking?
 A: Are you ever ANNOYED when someone
questions the amount you drink?
 G: Do you ever feel GUILTY about your
drinking?
 E: Do you feel you need an EYE-OPENER in
the a.m.?
TACE
 T: How many drinks does it TAKE to
make you feel high?
 A: Have people ANNOYED you by
criticizing your drinking?
 C: Have you felt you ought to CUT
down?
 E: Do you feel you need an EYEOPENER in the a.m.?
HALT
 H Do you usually drink to get HIGH?
 A Do you drink ALONE?
 L Do you ever find yourself LOOKING
forward to drinking?
 T Have you noticed whether you
seem to be becoming TOLERANT
of alcohol?
BUMP
 B “Have you ever had BLACKOUTS?”
 U “Have you ever used alcohol in an
UNPLANNED way?”
 M “Do you ever drink alcohol for
MEDICINAL reasons?
 P “Do you find yourself PROTECTING
your supply of alcohol?”
FATAL DT
F
A
T
A
L
D
 T
“Is there a FAMILY history of alcoholic
problems?”
“Have you ever been a member of
ALCOHOLICS Anonymous?”
“Do you THINK you are an alcoholic?”
“Have you ever ATTEMPTED or had
thoughts of suicide?”
“Have you ever had any LEGAL problems
related to alcohol consumption?”
“Do you ever DRIVE while intoxicated?”
“Do you ever use TRANQUILIZERS to steady
your nerves?”
Review of Systems
 General Health
Survey
 Diet
 Integumentary



Skin
Hair
Nails
 HEENT
 Head and Neck
 Eyes
 Ears
 Nose and Sinuses
 Mouth and Throat
Review of Systems
 Respiratory
 Male Reproductive
 Cardiovascular
 Musculoskeletal
 Breast
 Neurological
 Gastrointestinal
 Endocrine
 Genitourinary
 Hematologic/
 Female
Reproductive
Immune
Physical Exam
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General appearance
Vital signs
Head, neck
Eyes, ears
Chest, pulmonary
Heart, peripheral vascular
Skin
Abdominal
Musculoskeletal
Mental status
Neurological
Female genital, breast
Male genital, rectal
How do you document
the encounter?
Documentation
 SOAP
 SOAPIE
 DAR
 PIE
 Narrative
 Electronic Medical Records
Documentation

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Be accurate and objective.
Use acceptable abbreviations.
Be brief and to the point.
Document in short phrases.
Avoid “normal, usual, general, unremarkable”
Record pertinent negatives.
Include all required components


Include only subjective in S
Include only objective in O
 Associate each plan with corresponding assessment
 Date and sign documentation.
Subjective
 Definition: Of, relating to, or designating a
symptom or condition perceived by the
patient and not by the examiner.
 Begins with chief concern
 Includes all of HPI
 Portions of Functional history
 Portions of PMH
 Pertinent SH, FH
 Pertinent ROS
Objective
 Definition: Indicating a symptom or condition
perceived as a sign of disease by someone other
than the person affected.
 Begins with general observations
 Includes vital signs
 Includes systems based exam based on
symptoms and understanding of
anatomy/physiology/pathology
 Diagnostic data: laboratory, x-ray, etc.
Sample SOAP Note (With Errors)
Subjective
Cc: “she says she has a sore throat”
51 year old female appears her stated age, alert, cooperative in no acute
distress. Patient was well until 2 days ago when she awoke and
noticed a sore throat, progressively worse throughout the day. Pain is
constant, “scratchy” ache, rated 4/10, and radiates to the right ear
with swallowing. Pain is aggravated by swallowing; relieved with salt
water gargles and Chloraseptic spray.
Objective
Temp 98.7 F but she says she felt hot, PR 60 bpm, RR 14 bpm, BP
sitting R arm 110/70
Throat: she says she has a lump in her throat; tongue not coated, uvula
midline without ulcerations, tonsils prominent with erythema but no
exudates
Lungs: clear to auscultation without wheezing
Assessment
She’s worried this is Strep throat
Plan
Diagnostic tests: throat culture
Treatment: patient asked for antibiotics
Patient education: Associates degree in information technology
Sample SOAP Note
Subjective
Cc: “My throat is really sore”
Patient was well until 2 days ago when she awoke and noticed a sore throat, progressively
worse throughout the day. Pain is constant, “scratchy” ache, rated 4/10, and radiates to the
right ear with swallowing. Pain is aggravated by swallowing; relieved with salt water gargles and
Chloraseptic spray. She reports feeling hot but has not measured her temperature and feels the
sensation of
lump in her throat, mostly on the right side. She believes this could be Strep throat and is concerned she
is
contagious to others. She has a history of Strep throat in high school with similar symptoms.
Objective
51 year old female appears her stated age, well developed, well nourished, alert, cooperative in no acute
Distress with no notable characteristics.
Temp 98.7 F (orally), PR 60 beat per minute, RR 14 breaths per minute, BP sitting R arm 110/70mmHg
Throat: tongue not coated, uvula midline without ulcerations, tonsils prominent with erythema but no
exudates
Lungs: clear to auscultation without wheezing
Assessment
1. Possible Strep throat
2. Medication renewal: Synthroid
Plan
1. Diagnostic tests: throat culture
Treatment: antibiotics if throat culture positive
Patient education: medication schedule, change toothbrush, encourage oral hydration
2. Diagnostic tests: blood TSH level in 6 months
Treatment: Synthroid 100mcg po qd Disp 30 day supply with 5 refills
Patient education: review symptoms of hypo and hyperthyroidism