Interviewing & Documentation
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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 Nursing Interview Not! The Nursing Interview… More Like This! The Interview The Interview Subjective data Results of a successful interview The interview as a contract between patient and examiner ◦ Time and place The Interview The Interview Subjective data Results of a successful interview The interview as a contract between patient and examiner ◦ ◦ 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 ◦ ◦ ◦ 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 ◦ ◦ ◦ ◦ 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 ◦ ◦ ◦ ◦ ◦ 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 ◦ ◦ ◦ ◦ ◦ ◦ Time and place Introduction and explanation Purpose Length Expectations Confidentiality The Interview Process of Communication Sending You are most aware of Verbal communication: words, voice Inflection / tone. Be aware of the Non-verbals that you send as well! Work on them. The Interview Process of Communication Sending Receiving Context gives meaning to the messages you send. The Interview Process of Communication Sending Receiving Internal factors Liking others Empathy Ability to listen LISTENING is not a passive process The Interview Process of Communication External factors Ensure privacy Refuse interruptions Physical environment Dress (Attire & Condition) Note-taking Tape and video recording 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 Open-ended questions Closed or direct questions 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 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 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 http://www.youtube.com/watch?v=gpVjW30I-YU 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 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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
