Comprehensive Health History Taking

Abstract

A patient interview entails collecting the medical and family history of a patient along with any other information that could be relevant to the health care practitioners in charge. This means that the interview techniques in use must be effective and substantial enough in terms of the information obtained. With the help of this exercise, it has been established that patients are best interviewed with a combination of the questionnaire and oral interview. Each of these two techniques has a separate set of merits that make it formidable in the acquisition of important information. When it comes to eliciting the patient’s interpretation of their health status, perceived barriers, and support, a patient-centered approach must be coupled with cultural competence thus ensuring that the interviewer motivates the patient to share this information voluntarily and with honesty.

Introduction

Collecting information on the patient is by far the most important step in administering health care. This information will help the practitioner to find solutions for the patient’s problems and thus the applied interview techniques need to be effective and thorough. Effectiveness here is a measure of the details in the collected information and its thoroughness is the extent to which it will answer the physician’s questions and guide them in understanding the patient’s problems. The interview must also consider the patient’s opinion of their problem and possible solutions especially if they entail behavior change and other long-term commitments. This paper presents a summary of effective interview techniques used for obtaining patients’ health history.

The Interview Techniques

The first effective technique is the use of a written questionnaire in which the patient’s details can be filled out easily in legible shorthand. The questionnaire helps the patient to summarize all the information that is considered necessary in terms of their health situation and thus it reduces the amount of time wasted on trivialities where there are no guiding questions (Bickley & Szilagyi, 2012). This technique is considered effective because the patient is enabled to provide all the information in a rather relaxed setting. Interviews can be uncomfortable for some people and thus, when they have an opportunity to write their medical history, they feel more comfortable about it.

An oral interview is another effective alternative that can be used by the practitioner to gather information. If the patient is especially incapacitated or unable to read or write for one reason or another, the oral interview is a way of ensuring that they can give as much information as they can regarding their medical history. This is most effective because it enables the practitioner to interact at a personal level with the patient thus building trust and making them comfortable. The oral interview can then be recorded directly in a computer database for future reference by the physician in charge.

How to Elicit the Patient’s Interpretation of Their Health Status, Perceived Barriers, and Support

The patient’s viewpoint is an important consideration when there is a need to come up with a work plan for their treatment. They need to be fully aware of their situation if they are to participate in the process of treatment. It can thus be admitted that the health care practitioner must be able to elicit the patient’s interpretation of their health status, perceived barriers, and support, especially through the oral interview technique. To accomplish this, the health care provider must strive for a patient’s centeredness and cultural competence in the interview (Viljoen, 2009).

A patient-centered interview is an interview, in which the patient is allowed to speak their mind and every question is about how they feel, think or what they know or expect with regards to their condition. The point of a patient-centered interview is to ensure that the patient’s thoughts are shared and that all of their concerns, fears, and misgivings are addressed on time. The patient’s cooperation and trust depend on how much they know, and focusing on this will enable them to offer as much information as possible thus enabling the practitioner to understand their interpretations and make the necessary corrections if needed.

Cultural competence, on the other hand, determines how the practitioner communicates with the patient. This is an important consideration because some patients can read the practitioner’s concerns wrongly if measures are not taken to understand their cultural contexts and practices with regards to communication and health care (Dillon, 2007). If the practitioner uses the right diction, gestures, facial expressions, and overall body language, they will be able to encourage the patient to share their thoughts during the interview.

Effectiveness of the History Taking Techniques

The Questionnaire

The written questionnaire is often a set of questions that guide the patient on the kind of information that the doctors will find useful. The questionnaire has both closed and open-ended questions. The aim is to ensure relevance and brevity without limiting the patient from explaining their exact situation. It can be admitted that the questionnaires are especially effective for several reasons including;

Brevity

Questionnaires are known for their brevity when it comes to the healthcare setting. This is mainly because the patients are not always in the position to go through countless pages of questions, multiple-choice, etc. There is thus a need for these questions to be limited to those that are especially important for the patient’s condition. This limitation makes the questionnaires very brief and straight to the point. As such, they often depend on the focused ROS’s for specificity (Purnnel, 2008).

Clarity

Most questionnaires are very clear in terms of the questions and for the most part, the answers are either affirmative or negative. The parts that require explanations are also often very concise thus making the entire form very basic and easy to understand. It can be admitted that this form is used for reference and also for the creation of a patient database, and thus clarity is a significant attribute of an interview technique.

Relevance

All the questions in the questionnaire are aimed at eliciting a response that will be important to the health care provider at one point or another. This means that every aspect of the questionnaire is tailored to be relevant to the patient’s condition. The relevance here ensures that the patient provides only information that will be significant for their diagnosis and treatment as opposed to dwelling on sideshows (Purnnel, 2008). As such, the interview becomes very time-efficient and both doctors and patients get to the process of treatment soon enough.

Convenience

Most people feel more comfortable writing than speaking to another person, especially on personal health matters. The concept of writing down history is thus more appealing than having to discuss it with a health practitioner. The convenience, in this case, allows the patient some comfort, as they do not have to talk about their health issues.

The Oral Interview

This entails a detailed discussion with the health care provider and in most cases, it covers not only medical history but also social and family history, expectations and probable solutions to the problems at hand. This alternative has some significant advantages that include the opportunity of the practitioner to gather details. From the discussion with the patient, the physician can determine the patient’s physical and psychological status thus getting much more insight than would have been possible when using a different technique. The personal interaction between the patient and their health care provider also opens up the door to the formation of warm relationships built on trust and genuine concern. This makes the patient easier to treat as they believe in the doctor (Purnnel, 2008).

Conclusion

Interviewing a patient is not an entirely easy task and yet it is one of the most basic aspects of health care practice. The two most effective patient interview techniques are the questionnaires and oral interviews, which in ideal are used together. These techniques are very effective in their respective contexts and when used together they provide many impressive results. For eliciting the patient’s perspective on their health status, perceived barriers, and support, it is often important to consider taking on the patient-centered approach and applying cultural competence as seen necessary within the circumstances at hand.