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![“Good morning, Mr. Rios. My name is [Your Name], and I’m a
nursing student collaborating with your healthcare team today.
I’d like to ask you some questions to gain a better understanding
of your health concerns and how we can provide the best care for
you. Everything we discuss will remain confidential, and you are
welcome to share as much as you feel comfortable. Does that
sound okay to you?”
WHAT TO SAY:
WORKING (DATA COLLECTION)
Phase
Gather client’s:
01
• Chief complaint
• History of present health concerns.
• Past health history
• Family health history
• Lifestyle and health practices
• Review of Systems
• Developmental Level
02
WORKING (DATA COLLECTION)
Phase
02
02
03
Use active listening and therapeutic
communication techniques.
Ask both open-ended (to encourage
conversation) and closed-ended (to get
specific details) questions.
▪ Use open-ended questions first.
▪ Follow up with closed-ended questions for specific details.
▪ Observe non-verbal cues (facial expressions, body language)
▪ Paraphrase or summarize responses to ensure understanding.
▪ Use of COLDSPA (Character, Onset, Location, Duration, Severity, Pattern,
Associated factors)
WHAT TO DO:
WHAT TO SAY:
▪ Can you tell me more about what brought you to the hospital today?” (Open-ended)
▪ “When did the pain start, and how would you describe it—sharp, dull, or throbbing?”
(Closed-ended)
▪ “I see that you’re holding your stomach. Is the pain located there?” (Observational)
▪ “It sounds like you’ve been feeling very fatigued lately. How has this been affecting
your daily activities?” (Reflective listening)](https://image.slidesharecdn.com/group2-250403133028-b3967416/75/Phases-of-interview-documentation-and-assessment-2-2048.jpg)
Phases of interview, documentation, and assessment
- 1. PHASES OF INTERVIEW Members: GROUP2 SECTION F MW 4:00-5:30PM BROWN, JOSEPH ANTHONY CATAMURA, NICOLE CRUZ, MARIANNE CALLEJO, CHRISTOPHER DELOS REYES, KURT ADRIAN DOCUMENTATION ASSESSMENT Introduction Effective patient interviews are essential in healthcare, serving as the foundation for accurate assessment, diagnosis, and care planning. As nurses and healthcare professionals, we must approach patient interviews systematically to ensure trust, clarity, and comprehensive assessment. A well-structured interview follows distinct phases that help guide the conversation smoothly, ensuring both the patient and the healthcare provider achieve their goals. PHASES OF Interview 01 02 03 Introduction Phase Working Phase Closing/Termination Phase INTRODUCTORY (ORIENTATION) Phase Establish rapport and trust 01 02 03 Explain your role and the purpose of the interview. Ensure patient comfort and gain consent for the interview. WHAT TO DO: ▪ Greet the patient warmly. ▪ Introduce yourself (name, role, purpose of the interview) ▪ Explain confidentiality and obtain consent. ▪ Observe patient’s body language and comfort level.
- 2. “Good morning, Mr.Rios. My name is [Your Name], and I’m a nursing student collaborating with your healthcare team today. I’d like to ask you some questions to gain a better understanding of your health concerns and how we can provide the best care for you. Everything we discuss will remain confidential, and you are welcome to share as much as you feel comfortable. Does that sound okay to you?” WHAT TO SAY: WORKING (DATA COLLECTION) Phase Gather client’s: 01 • Chief complaint • History of present health concerns. • Past health history • Family health history • Lifestyle and health practices • Review of Systems • Developmental Level 02 WORKING (DATA COLLECTION) Phase 02 02 03 Use active listening and therapeutic communication techniques. Ask both open-ended (to encourage conversation) and closed-ended (to get specific details) questions. ▪ Use open-ended questions first. ▪ Follow up with closed-ended questions for specific details. ▪ Observe non-verbal cues (facial expressions, body language) ▪ Paraphrase or summarize responses to ensure understanding. ▪ Use of COLDSPA (Character, Onset, Location, Duration, Severity, Pattern, Associated factors) WHAT TO DO: WHAT TO SAY: ▪ Can you tell me more about what brought you to the hospital today?” (Open-ended) ▪ “When did the pain start, and how would you describe it—sharp, dull, or throbbing?” (Closed-ended) ▪ “I see that you’re holding your stomach. Is the pain located there?” (Observational) ▪ “It sounds like you’ve been feeling very fatigued lately. How has this been affecting your daily activities?” (Reflective listening)
- 3. CLOSING/TERMINATION Phase Confirm accuracy ofthe information gathered. 01 02 03 Summarize key points of the discussion. Allow the patient to clarify or add more details. 03 Conclude the interview professionally. 03 Provide information on what happens next. 03 Ensure the patient knows how to follow up or ask further questions ▪ Briefly repeat what the patient has shared. ▪ Ask if there’s anything they would like to add. ▪ Validate their concerns and reassure them. ▪ Let the patient know the interview is ending. ▪ Provide next steps ("The doctor will see you soon" or "We will run some tests") WHAT TO DO: WHAT TO SAY: ▪ “So, to summarize what we’ve discussed, you mentioned that you’ve been experiencing chest pain for the past two days, especially when walking or climbing stairs. You also said the pain feels like pressure, but it goes away when you rest. Is that correct?” ▪ “Did I miss anything important that you would like to add?” ▪ “Thank you for sharing all of this with me. It really helps us understand what you’re going through, and we’ll work together to address your concerns.” DOCUMENTATION Nursing documentation refers to the written or electronic records created by nurses that detail patient assessments, interventions, and outcomes. It conveys clinically relevant information to the healthcare team, enabling informed decision- making and coordinated care. Purpose: COMMUNICATION Documentation acts as a legal record that can be used in court to demonstrate the care provided and the rationale behind clinical decisions. LEGAL EVIDENCE It supports quality assurance initiatives by providing data for evaluating care effectiveness and outcomes. QUALITY ASSURANCE Accurate documentation is necessary for billing purposes, as it substantiates the services rendered to patients. REIMBURSEMENT COMPONENTS OF NURSING DOCUMENTATION ADMISSION FORMS These provide basic client information and initial assessments upon admission to a healthcare facility. CARE PLANS These outline the nursing diagnoses, goals, interventions, and expected outcomes for patient care ASSESSMENT RECORDS Nurses document comprehensive assessments that include physiological, psychological, sociological, and spiritual evaluations. PROGRESS NOTES Ongoing notes that reflect changes in patient status, responses to interventions, and any modifications to the care plan.
- 4. Documentation should becompleted PROMPTLY after care is provided to maintain accuracy and relevance. Nurses should document FACTUAL OBSERVATIONS and avoid subjective interpretations. This includes using clear medical terminology and avoiding abbreviations in legal contexts. All relevant information regarding patient assessments, interventions, and responses should be documented thoroughly to provide a comprehensive view of patient care. Documentation must adhere to privacy regulations such as HIPAA to protect patient information. STRATEGIES FOR EFFECTIVE NURSING DOCUMENTATION ASSESSMENT A comprehensive assessment in nursing is crucial for understanding a patient's needs, readiness to learn, interests, and problems, as well as their learning styles. This process forms the foundation for effective nursing care and educational interventions. Factors to consider: 01 02 03 Readiness to learn Learning needs Interests and Problems 03 Learning Styles Involves determining when a patient is receptive and willing to engage in the learning process. It is essential to assess both the emotional and cognitive readiness of the learner. Factors such as the patient's emotional state, level of understanding, motivation, and physical condition can affect readiness. READINESS TO LEARN LEARNING NEEDS Effective communication is key in nursing assessments. Nurses must listen actively to understand patients' concerns and preferences, which informs care planning and educational strategies. This can be done through direct questioning, surveys, or discussions about the patient's concerns and goals. Understanding what topics the patient is interested in learning about and any specific problems they face that may hinder their learning. Engaging in open conversations to explore the patient's interests and challenges related to their health. INTERESTS AND PROBLEMS LEARNING STYLES Understanding different learning styles is essential for tailoring educational interventions. Assessing these styles can involve questionnaires or informal observations during interactions.
- 5. TYPES OF LEARNINGSTYLES VISUAL LEARNERS Prefer diagrams, charts, and videos. AUDITORY LEARNERS Benefit from discussions and verbal explanations. KINESTHETIC LEARNERS a.k.a. Tactile learner, Learn best through hands-on experiences. Patient interviewing, thorough documentation, and comprehensive assessment form the cornerstones of effective nursing practice. Skillful interviewing uncovers crucial patient information, while detailed documentation ensures continuity of care and clear communication. By prioritizing these elements, nurses enhance patient safety, personalize treatment plans, and drive positive health outcomes. Conclusion Thank You REFERENCES https://openstax.org/books/clinical-nursing-skills/pages/3-2-comprehensive-interview-practices https://en.wikipedia.org/wiki/Nursing_documentation https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing-documentation-principles/ https://wtcs.pressbooks.pub/nursingfundamentals/chapter/2-5-documentation/ https://www.masmedicalstaffing.com/blog/the-importance-of-nursing-documentation-a-comprehensive-guide/ https://nursekey.com/determinants-of-learning/ https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6088726/ https://www.studocu.com/en-ca/document/centennial-college/health-assessment/2health-education- process/15395163