Patient Interview
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Chief complaint- subjective statement
regarding most significant symptoms or
signs of illness
Description of general health
Description of lifestyle
Changes in status since last visit
All info is considered confidential!!
Components
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The interview will become part of a legal
document- follow the 6 c’s
Client’s words in quotation mark’s
Clarity
Completeness
Concise
Chronological
Confidentiality
6 C’s
Private area without interruptions
 Develop plan before interview, look up pt.
hx, chronic problems, meds etc…
 Use broad knowledge base- look up
diseases, drugs tests, etc.. That you don’t
know
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Tips for successful interview
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Open-ended
Hypothetical questions
Mirroring response
Focusing on pt.
Encouraging pt. to take lead
Encouraging pt. to evaluate his/her
situation
Effective questioning
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Closed-ended questions
Leading questions
Challenging
Probing
Agreeing or disagreeing
Ineffective questioning
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Methods include: inspection, palpation,
percussion, auscultation, mensuration,
manipulation
Examination of pt.
Neurological: LOC- level of consciousness
and orientation to person, place and time.
Motor ability- ambulation. Senses,
speech, hearing, vision
 Cardiovascular/pulmonary:
characteristics of peripheral(arm/leg)
pulses. Characteristics of respirations:
shallow, deep, regular, dyspnea, SOB.
Breath sounds- crackles/rhonchi, rales,
wheezes, diminished, labored. Coughproductive or nonproductive
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Components of general physical
exam
Integumentary: wounds, scars,
ecchymosis, contracture, rash,
lacerations, decubitus ulcers. Color,
temp., surgical incisions, stitches, staples
 Musculoskeletal: contractures,
amputation, deformity, atrophy, ROM,
ambulation, fractures, dislocations
 Gastrointestinal: Abdomen, bowel
sounds, nutrition, NG tubes, special diets,
I&O
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Exam cont.
GYN/Reproductive: Date of LMP, breast
self-exam, testicular exam, problems
 Elimination: Stool- constipation, diarrhea,
date of last bowel movement. Urinevoiding, incontinent, dysuria, nocturia,
foley catheter, external catheter
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Exam cont.
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Psychosocial: affect, mood, anxious,
angry, conversant, defensive, noncooperative, combative. Living
environment: alone, with spouse, nursing
home, etc. Vocation/avocation: jobs,
hobbies, interests
Exam cont.
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Symptoms: Objective and subjective
Diagnostic tests and their results
Plan of action: meds, therapies,
surgeries, diet, activity level
Documentation of result of tx
Modification of plan
Pt. education
Components of tx plan
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S- subjective symptoms (pt. says)
O- objective sx (can be seen or
measured)
A-assessment, dx
P- plan (tx plan)
I- Implementation (putting plan in action)
E- evaluation (results of plan)
R-revision (change plan based on
evaluation)
SOAPIER
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Diabetes: inability of pancreas to produce
enough insulin resulting in lack of sugar
available for cell metabolism.
Symptoms: polyuria, polydipsia,
polyphagia, sudden weight loss
 Diagnostic tests: Fasting blood sugar,
glucose tolerance test
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Sample treatment plan
Plan of action: insulin SQ, ADA diet,
moderate exercise
 Pt. education: use of glucometer, insulin
injections, symptoms and treatment of
insulin shock, care of infections, care of
feet (prone to develop foot ulcers that can
result in amputation)
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Treatment plan cont.