GATHERING INFORMATION

One of the most puzzling concerns for students beginning clinical experience involves therapeutic interaction and determining patient needs. This leads to the question: “How will I know what to ask?” Unfortunately, there is no single best answer. The questions needed to determine the root of a patient’s problem are as different as the presenting illnesses and the patients themselves. For example, presume you ask Mr. Martin, “How may we help you today?” and he answers, “I think I have the flu.” This simple, very common response leads to a multitude of questions. The progression of questions is very different if Mr. Martin is young and otherwise healthy than if he is elderly with hypertension and insulin-dependent diabetes mellitus. Every question and every response will be as individual as each patient’s history and current concern. A skilled professional learns to follow a logical progression from the simplest “What can we do for you?” or “How may I help you?” to the most probing, in-depth evaluation of the patient’s problem.

To make gathering information easier, and to ensure that all necessary points are covered, some specialties develop algorithms for specific complaints (Fig. 3-1). An algorithm states an issue and offers paths to follow, depending on the patient’s answer at each step. For example, if the answer to a specific question is “yes,” a suggestion for the next question follows. If the answer is “no,” the next question follows a different pattern. This works well in some instances but may not allow for individual responses. An algorithm system may be too focused for individual patients, or too general for a focused interview. However, even the most inadequate algorithm at least leads in a general direction of questioning that the physician prefers.

Another tool to help with a preset plan, and to cover as much necessary information as possible, is the use of acronyms. An acronym is a simple phrase or word with a question coordinated for each letter. Acronyms are easy to remember. Questions may be either general or specific, with additional questions added based on each answer you receive. For example, Box 3-1 shows an acronym—MDVISIT—that could be used for a routine physician’s office visit. As the patient answers each question, remember that even the best acronym or algorithm will not replace your responsibility to adjust your questions based on what you see or hear during the time you spend with the patient.

Physicians have preferences for information to cover and record at each encounter, and then usually need other information depending on the patient’s current complaint. For example, you need to know what additional information the physician needs if the concern is chest pain versus joint pain. Once the requirements are clear for specific situations, record this in an agency protocol, such as the Policy and Procedures manual, to use as a guide and to help keep interactions and documentation complete and relevant.

Talking with patients to determine a current history requires most of the following points:

Knowing what to ask and what to do next is a skill acquired with practice. With rising demands on the time allowed for each patient, information you discover during the interaction or exchange should suggest steps to follow and procedures to perform before passing the patient’s care to the next member of the health care team. For example, consider a situation involving an elderly patient (Mr. Martin) who has chronic health problems (insulin- dependent diabetes mellitus) along with an acute illness such as a virus (described above). In addition to routinely checking his vital signs, you should also check his blood sugar level and question him to make sure he is following his health care routine. Document this information and report to his physician. If the situation involves a younger, otherwise healthy patient, gather and record basic information, but glucose levels are not necessary. As another example, if Mrs. Smith complains of burning on urination, your responsibility and scope of practice might include obtaining a clean-catch midstream urine specimen in addition to routine vital signs. Gathering additional information by performing appropriate preliminary procedures expands on the current health complaint and provides the physician with information needed for a full diagnosis. Without full knowledge of the patient’s past and current history, vital information may be overlooked, which may require backtracking and duplicated effort. If you do not follow a possible line of questioning and miss an issue of concern, time is wasted while the physician, instead of you, determines the full scope of the complaint. Our goal is to know as much as possible about our patients by gathering information effectively before any procedure begins.

SETTING THE STAGE

Current information is gathered and recorded with every patient contact, whether in person, by phone, or by written communication. Since most patient contact is on a personal basis, this text presumes that you and the patient are sharing a verbal exchange.

Whenever possible, the medical environment should be professional but friendly, not cold and sterile. Warm, bright colors and a comfortable setting help put patients at ease. The area should be private with no interruptions to threaten confidentiality or to disrupt the flow of the conversation. Practice good personal hygiene and proper grooming to make a good impression and to establish or maintain rapport and respect for your professionalism (see the Spotlight on Success box).

The following suggestions should help make each exchange of information more effective:

• Before you begin, review the patient’s chart. Knowing the patient’s background and medical history shows that you are interested and concerned and gives you an idea of the questions you should ask.

• Sit in a comfortably relaxed and open position; crossed arms transmit rejection, rigid posture is intimidating, and slouching is unprofessional.

• Sit at the patient’s level, face-to-face. If it is culturally acceptable to the patient, maintain eye contact.

• Show your interest by appropriate facial and nonverbal expressions, such as smiling and nodding.

• Listen attentively and stay centered on the conversation. Patients are aware when you are not listening.

• Start with general questions, such as “How may we help you today?” and work toward more probing questions. Working from simple to complex gives you time to establish rapport and builds the information background.

• Phrase your questions to require an extended response in the patient’s own words, unless you need specific information. This is called open-ended questioning and requires that patients form answers in their own words. Closed-ended questions require brief, specific answers. (See “Getting to the Point,” later in this chapter, for further discussion of these concepts.)

• Remember incongruence? Look for cues that conflict with the patient’s statements of concern. What is actually bothering this patient? There may be much more to discover than the initial or presenting complaint.

• Remember that many responses are subjective, or obvious only to the patient; for example, pain to one patient may be discomfort to another. A small amount of blood to one patient may be hemorrhage to another. Closed-ended questions help clarify responses, such as exactly how much blood, or registering pain on a scale of 1 to 10 (Fig. 3-2).

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