病史采集(英文).ppt

Importance Data for making diagnosis Clue for PE, Lab and other examination Patient-doctor relationship Bio-psycho-social medical approach Always, the first step to treat patient A “good physician” A good observer A good communicator A good critic A good decision maker A good student--- now and later Basic Principles Communication Interviewer’s skill Establish trust Questions understandable to patient Interpreter if necessary Main purpose of interview Obtain basic information related to patient’s illness or reason for visit Basic Principles Interviewer Cheerful, friendly, but respectful and genuinely concerned about the patient Novice interviewers Have to gain experience asking questions about subjects that are more painful, delicate or unpleasant Permit patient to express themselves in their own words Basic Principles If patient gives a vague history Ask more direct questions Listen without any suggestion of prejudice Treat all patients with respect Regardless of their age, gender, beliefs, intelligence, educational background, legal status, practices, culture, illness, body habitus, emotional condition, or economic state Basic Principles Follow the “rule of five vowels” udition Listen carefully valuation Sort out relevant from irrelevant data nquiry Probe into significant areas requiring more clarification bservation Importance of nonverbal communication Regardless of what is said nderstanding Of patient’s concerns and apprehensions Play empathetic role General: Greet the patient Adequately identify yourself and your purpose Allow patient’s privacy and comfort during exam Identify Yourself Use Mr./ Mrs./ Ms (Patient’s name) formal address clarifies the professional nature of the interview Ex: I am a medical student working for (Preceptor’s Name) who has asked me to do an interview and general examination for you. My name is ….. General Data  Name ● Native place Sex ● Address Age ●