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Patient Interview Script Guide

The document provides a comprehensive outline for obtaining a patient's history, including templates for: introducing oneself; gathering the chief complaint and details of the present illness; reviewing past medical, family, social, and surgical histories; and conducting a thorough systems review. The guide emphasizes obtaining patient-centered information in a respectful manner to fully understand the clinical situation and formulate an appropriate treatment plan.

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72 views6 pages

Patient Interview Script Guide

The document provides a comprehensive outline for obtaining a patient's history, including templates for: introducing oneself; gathering the chief complaint and details of the present illness; reviewing past medical, family, social, and surgical histories; and conducting a thorough systems review. The guide emphasizes obtaining patient-centered information in a respectful manner to fully understand the clinical situation and formulate an appropriate treatment plan.

Uploaded by

lu
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

QUESTIONS TO ASK FOR HISTORY PORTION OF PATIENT INTERVIEW

INTRODUCTION

● Introduce self by name, “Hello, I am ____ and I am going to be the PA student assisting with
your care today.”
● State Washed Hands, “I am going to wash my hands and I’ll be over to talk with you shortly.”

● “Can you tell me your name and birthday? How would you like me to address you?”

● “Alright [Patient Preferred Name], my goal today is to get some background information on
you and the situation at hand, so I’ll be asking you a lot of questions. Is that something you
will be comfortable with?” Allow patient response. “Wonderful. My first question is, what
brings you in today?”

HISTORY OF PRESENT ILLNESS (HPI)

● CHIEF COMPLAINT
o Needs to be in patient’s own words
o Try to understand patient’s agenda first
▪ To ensure you have the entire list of concerns, repeat it back
o With multiple complaints, it may be important to prioritize
● LOCATION
o Primary area it occurs
o “Can you point to me where you’re experiencing pain?”
● TIMING
o ONSET: Gradual vs. Sudden
o DURATION: Amount of time CC present
o FREQUENCY: number of times the CC occurs, how often it develops
o “When did the CC first start? How long did it last? Did it occur suddenly or was it
gradual? Is it always hurting, or does it come and go? How many times does it occur in
a day?”
● SETTING
o Actual physical environment or activity in which the chief complaint is involved
▪ Can also be determined by a mental state
o “What were you doing when the chief complaint first presented itself?”
● QUALITY
o Describes the way it feels to a patient
o “Can you tell me what this pain feels like?”
● QUANTITY
o Depicts severity, volume, number, or extent of chief complaint
o “Can you rate your pain on a scale from 1-10? 1 – being no pain at all, 10 being the
worst pain in the world”
o “How would you describe your pain? Mild, moderate, or severe?”

● RADIATION
o Spreading of the symptom or other CC from original location elsewhere
o “When you have this pain, does it spread out to any other part of the body?”
● AGGRAVATING FACTORS
o Factors that worsen the severity of the chief complaint
o “Is there anything that you have done that makes this pain worse?”
▪ “When you stopped this activity, did it make it better?”

● ALLEVIATING FACTORS
o Factors that decrease the severity of the chief complaint
o “Is there anything that you can do to manage it? Have you taken any medications?”
● ASSOCIATED MANIFESTATIONS / SYMPTOMS
o Signs and symptoms that accompany the CC.
o PERTINENT POSITIVE: associated manifestations that a patient has experienced with the
chief complaint
o PERTINENT NEGATIVES: Manifestations suspected, but denied by the patient
● Repeat back enough information that the patient knows that you fully understand the
problem they have at hand, but do not get so detailed that it takes away from you time with
questioning.
● “Alright, so now I’m going to be asking you a lot of questions. Some of them may feel a little
personal, but it is important that we talk openly about what’s going on with you so we can
make sure you have the best care possible. Is that okay?”

PAST MEDICAL HISTORY (Food Exercise Drugs – Tobacco Alcohol Caffeine Occupation Sex)

● CHILDHOOD ILLNESSES
● ADULT ILLNESSES
o Medical / Psychiatric / Chronic Illness
● SURGERIES / INJURIES / HOSPITALIZATIONS

● CURRENT MEDICATIONS
o Type, Dosage, Frequency
● ALLERGIES & DRUG REACTIONS
o Type, Reaction Extent
● SEXUAL PRACTICES
o “Are you currently sexually active? In the last year how many partners have you had?
Men, Women, or Both? Do you use a form of birth control, if so what? Have you in the
past or do you have any present concerns for STIs?”
● REPRODUCTIVE STATUS (females only)
o Pregnancies, Term births, preterm births, abortions, living children, pap smear,
mammogram
● IMMUNIZATIONS / VACCINES & HEALTH MAINTENANCE / DISEASE PREVENTION
o Colonoscopy, Prostate Exams, Contraception, breast exams

FAMILY MEDICAL HISTORY

● “Are there any health problems that run in your family?”


o History of cancer, diabetes, hypertension, psychiatric disorders, heart attacks, strokes,
death, or really anything you feel is important to mention in your family?
● GRANDPARENTS
o “Are your grandparent’s still living?” If not, “What did they pass from?”
● PARENTS

● SIBLINGS

● CHILDREN

SOCIAL HISTORY

● BIRTHPLACE / HOMETOWN

● HIGHEST LEVEL OF EDUCATION

● OCCUPATION

● RELATIONSHIP STATUS
● RELIGIOUS / SPIRITUAL BELIEFS

● TOBACCO USE
o Type, How Much, and How Long
● ALCOHOL USE
o Type, How Much, and How Long
● RECREATIONAL DRUG USE
o Type, How Much, and How Long
● DIET / EXERCISE

● WHAT DO YOUR DO TO ENJOY YOUR DAY?

REVIEW OF SYSTEMS

● GENERAL
o Have you had any sudden weight changes? Weakness? Fatigue?
● SKIN
o Changes with your hair? Skin? Nails? Have you had any recent rashes? Sores? What
about itching?
● HEAD
o Have you experienced any unusual headaches? Dizziness? Lightheadedness?
● EYES
o Have you had any change of vision? Redness? Dryness? Do you wear any corrective
lenses?
● EARS
o Any difficulty hearing? Ear Pain? Ringing sound? Discharge?
● NOSE/SINUSES
o Any nasal stuffiness? Nosebleeds? Sinus issues? Pain?
● THROAT
o Have you had a sore throat? Trouble swallowing? Bleeding gums? Dry mouth?

● NECK
o Any tender points on your neck like swollen lymph nodes? Any neck pain? Stiffness?
● BREASTS
o Do you perform regular self-breast exams? Have you felt any lumps? Had any pain?
Seen any nipple discharge?
● RESPIRATORY
o Any recent coughs? Shortness of breath? Wheezing? Pain when taking a deep breath?
● CARDIOVASCULAR
o Have you had high blood pressure? Chest pain? Palpitations (FEEL your heart beating)?
● PERIPHERAL VASCULAR
o Any swelling in your arms or legs? Skin temperature changes? Color?
● GASTRO-INTESTINAL
o Is your appetite remained normal? Any heart burn? Abdominal Pain? Nausea?
Vomiting? Diarrhea? Changes in your bowel movements? Stool consistency?
● URINARY
o Any frequency when urinating? Any inability to control your bladder? Any burning
sensation upon urination? Side pain? (MEN: Reduced stream force? Hesitancy?)
● GENITAL (MALE)
o Any hernias? Testicular pain? Any difficulty with sexual arousal? Functioning? Any STI
concerns? Discharge?
● GENITAL (FEMALE)
o When was your last menstrual cycle? Are you regular? Any bleeding between periods?
After intercourse? Any abnormal discharge? Itching?
● MUSCULOSKELETAL
o Any joint pain? Stiffness? Low back pain? Do you have any swelling? Have you had any
limited ROM? Any recent falls?
● NEUROLOGIC
o Any changes in attention? Speech? Orientation? Changes in memory? Judgement?
● HEMATOLOGIC
o Have you experienced any easy bruising? Had any blood transfusions or been told
you’re anemic or have low iron levels
● ENDOCRINE
o Have you had any changes in perceptions of temperature, possibly being extremely
too hot or too cold? Any excessive sweating? Excessive thirst? Fruity smelling breath?
● PSYCHIATRIC
o Have you had any anxiety? Depression? Fluctuating mood? Suicidal Ideation?

CLOSING

● “So I believe I have gathered all the information that I needed from you. Do you have any
questions for me before I go review this information with the doctor?”
● Allow patient time to ask questions, and answer them fully.

● “Alright. After I review this information with my supervising physician, we will come back and
talk about a treatment plan. Thank you.”

Common questions

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A detailed review of systems is essential for a thorough patient assessment as it systematically covers every major body system, potentially uncovering symptoms or conditions that the patient might not initially report, but which could be relevant. This comprehensive approach ensures a holistic understanding of the patient's health and can reveal interconnections between systems, aiding in differential diagnosis and ensuring no critical information is overlooked, thus facilitating a more accurate diagnostic process and effective treatment planning .

Including lifestyle factors like tobacco and alcohol use in a patient's medical history is significant because these habits have profound impacts on health, influencing the development and progression of numerous conditions such as cardiovascular diseases, cancers, liver disorders, and respiratory issues. Understanding these behaviors aids in comprehensive risk assessment and enables targeted interventions to encourage healthier lifestyle modifications, ultimately improving long-term health outcomes .

Restating the patient's chief complaint in their own words is crucial because it ensures that the healthcare provider accurately understands the patient's perspective and main concerns. It helps in building rapport and trust, allows the patient to feel heard, and can uncover underlying issues that the patient might not have explicitly mentioned. Moreover, this practice helps in prioritizing the concerns, especially when multiple issues are present, by aligning with the patient's agenda .

Discussing both aggravating and alleviating factors is crucial as it provides a comprehensive understanding of the symptom dynamics and their management. Aggravating factors can help pinpoint the root causes or activities that exacerbate a condition, while alleviating factors provide insight into what might be effective in relief or management, guiding treatment approaches. This dual insight also aids in understanding the patient's lifestyle and possible external influences on their health .

Reviewing a patient's past medical history in depth is beneficial as it can reveal patterns or predisposing factors tied to current health issues. It offers insights into chronic conditions, past interventions, and the patient's response to previous treatments. Knowledge of previous medical and psychiatric illnesses, surgeries, and hospitalizations can steer current diagnostic evaluations and inform risk assessments for new treatments or interventions. Additionally, understanding past medical history aids in predicting potential future health concerns .

Asking about a patient's mental state at the onset of symptoms can improve understanding of their condition by indicating if psychological factors play a role in symptom development or severity. Mental health issues such as stress, anxiety, or depression can manifest physically, influencing symptom perception and presentation. Understanding this relationship helps differentiate between purely physical conditions and those with psychosomatic components, guiding comprehensive treatment approaches that address both physical and psychological health .

Providing an opportunity for patients to ask questions and discuss concerns at the end of a medical history interview is important for patient engagement and satisfaction. It ensures that the patient feels involved in their care process and may provide additional information that influences diagnosis or treatment decisions. This dialogue encourages open communication, helps clarify any misunderstandings, and strengthens the patient-provider relationship, ultimately leading to better adherence to treatment plans and improved health outcomes .

Exploring the settings where a patient's symptoms occur can provide valuable context that aids in diagnosis. It can help identify environmental, physical, or emotional triggers contributing to the symptoms. For example, if symptoms arise during specific activities or in certain environments, it might indicate an occupational hazard or stress-related issue. By understanding when and where symptoms present or worsen, healthcare providers can tailor treatment strategies and preventative advice more effectively .

Inquiring about family medical history is pivotal in assessing an individual's risk for genetic diseases because it highlights hereditary patterns and predispositions. Conditions like cancer, diabetes, hypertension, and psychiatric disorders often have genetic links. By understanding a family's health history, healthcare providers can better predict potential health risks and recommend preventive measures or early screenings, thereby improving patient outcomes through personalized care .

Addressing sexual health practices during a medical history interview is crucial as it assists in evaluating risks for sexually transmitted infections (STIs), unintended pregnancies, and sexual dysfunction. It also helps in understanding the patient's need for STI screenings, contraceptive advice, or sexual counseling. This discussion is integral to personalized care, preventive health strategies, and holistic well-being, as sexual health significantly influences overall health status .

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