Chapter 22: Assessing the Child and Adolescent (co-author)
Jane Brophy, RN, MSN, CNM
Assistant Professor of Nursing
Trinity Washington University
Washington, DC
Chapter 21: Assessing the Newborn (co-author)
Kimberly Foisy, RN, MSN, CSMRN
Assistant Professor
Northern Essex Community College
Lawrence, Massachusetts
Chapter 17: Assessing the Neurological System (co-author)
Karen L. Gorton, PhD, RN, MS, ATC Ret.
Assistant Professor, Assistant
Dean of Undergraduate Programs
University of Colorado College of Nursing—Anschutz Medical Campus
Aurora, Colorado
Chapter 16: Assessing the Musculoskeletal System (co-author)
Meredith J. Scannell, RN, CNM, MSN, MPH, PhD(c)
Clinical Instructor
Northeastern University
Research Nurse
Center for Clinical Investigation
Brigham and Women’s Hospital
Boston, Massachusetts
Chapter 18: Assessing the Female Breasts, Axillae, and Reproductive System (co-author)
Leslie White, MSN, FNP-BC, APRN
Adjunct Faculty Nurse Practitioner
Yale University; Quinnipiac University
New Haven, Connecticut
Chapter 23: Assessment of the Pregnant Woman
Kimberly B. Porter, MNSc, RN
Assistant Professor
University of Arkansas Little Rock
Little Rock, Arkansas
Valeria Ramdin, PhD (c), APRN-BC, MS, CNE
Faculty/Clinical Instructor
Northeastern University
Boston, Massachusetts
Sherry Ray, MSN, RN
Nursing Faculty
Arizona State University Phoenix, Arizona
Paula Reams, PhD, RN, CNE, LMT
Professor, Chair Health Sciences
Kettering College
Kettering, Ohio
Kathryn Reveles, PhD(c), DNP, APRN, CNS, CPNP-PC
Associate Professor Houston Baptist University Houston, Texas
Catherine Rice, RN, EdD
Professor/Faculty in the Department of Nursing Western Connecticut State University
Danbury, Connecticut
Debra L. Servello, DNP, ACNP
Assistant Professor of Nursing; ACNP Coordinator
Rhode Island College Providence, Rhode Island
Joyce A. Shanty, PhD, RN
Associate Professor
Indiana University of Pennsylvania Indiana, Pennsylvania
Denise Schentrup, DNP, ARNP-BC
Clinical Assistant Professor
University of Florida Gainesville, Florida
Mendy Stanford, BSN, MSN/ Ed, CNE
Executive Director of Nursing and Allied Health
Treasure Valley Community College Ontario, Oregon
Rebecca Sutter, MSN, APRN, BC, FNP
Associate Professor, Nursing Northern Virginia Community College
Medical Education Campus Springfield, Virginia
Kathy Taydus Assistant Professor
Jamestown Community College Jamestown, New York
Elaine Della Vecchio, PhD, RN, CCRN
Assistant Professor New York Institute of Technology Old Westbury, New York
Judy Vansteenbergen RN, MSN
Adjunct Faculty
Quinnipiac University
Hamden, Connecticut
Southern Connecticut State University
New Haven, Connecticut
Amber Williams, DNP, APRN, FNP-BC, RNC-MNN
Director of RN-BSN and MSN-OL Programs
University of South Carolina
Columbia, South Carolina
Erica Yu, PhD, RN, ANP
Assistant Dean for Undergraduate Programs
University of Texas Health Science Center at Houston
School of Nursing Houston, Texas
Tamara Zurakowski, PhD, GNP-BD
Adjunct Associate Professor
University of Pennsylvania Philadelphia, Pennsylvania
Tammy Zybell, MSN, MBA, RN
Faculty Manager/Instructor
Chamberlain College of Nursing Homosassa, Florida
Understanding Health Assessment 1
INTRODUCTION
The foundation of the healthcare delivery system is the interdisciplinary team that cares for the patients. Currently, there are about 3.6 million registered nurses (RNs) who provide care and assess patients in many different settings (American Nurses Association, Inc., 2017). Health assessment is a priority nursing skill that is the cornerstone of nursing care (Fawcett & Rhynas, 2012).
The Robert Wood Johnson Foundation Initiative on the Future of Nursing (2010) at the Institute of Medicine sought to build a blueprint for the future of nursing as part of larger efforts to reform the healthcare system (Institute of Medicine, 2010). The U.S. healthcare system is evolving, and care is becoming more focused on wellness, disease prevention, health promotion, and chronic illness management. In addition, healthcare reform provides many people with access to health care that they did not have previously. As a result, there continues to be an increased demand for everyday care through community health centers, professional home healthcare services, long-term care facilities, primary care providers’ offices, and nonemergency settings that are close to home.
In 1981, the World Health Organization (WHO) adopted a program called Global Strategy for Health for All by the Year 2000. “Health for All” does not mean an end to disease and disability or that physicians and nurses will care for everyone. It means that resources for health are evenly distributed and that essential health care is accessible to everyone (WHO, 2016). Health for All proposes that health begins at home, in schools, and in the workplace and that people use better approaches for preventing
illness and alleviating unavoidable disease and disability. In all settings, nurses are essential to ensuring access to needed care, and their knowledge and skills directly affect the quality of care that patients receive. In these areas, all patients need to be assessed by nurses.
Nursing is a practice profession. Health assessment is an essential skill to nursing practice. Assessing patients and being able to identify normal from abnormal findings is an essential role of the RN. Nurses must be able to use learned skills to collect information about patients’ health and physical well-being.
There are growing trends of changing demographics and increased diversity throughout the world. Nurses assess individuals of different cultures across the life span and in every practice setting from birth to the end of a patient’s life. Every person is unique, and each culture has its own health beliefs and practices. Cultural practices influence an individual’s behavior to promote, maintain, and restore health and how, when, and with whom they seek help or treatment (Dossey & Keegan, 2013). Cultural considerations are important when assessing patients.
Assessment requires each nurse to be like a detective, investigating everything about what the individual reports, observing their nonverbal body language, and looking for clues that may indicate something out of the ordinary. Assessment is a skill that uses most of our perceptual senses: hearing, seeing, smelling, and feeling. Assessment skills are learned and need to be practiced to master the techniques of assessing an individual.
LEVELS OF HEALTH PREVENTION
Preventative services include screening for disease, counseling, medications to prevent disease, and immunization recommendations. An individual’s community can also enhance health promotion through social and environmental programs (Dunphy, Winland-Brown, Porter, & Thomas, 2013). There are three levels of prevention:
1. Primary prevention is the prevention of disease and disability and focuses on improving an individual’s overall health and well-being (e.g., immunizations and health education).
HEALTH ASSESSMENT
Health assessment means assessing the whole patient. This includes:
■ a method to establish a baseline health history by collecting pertinent patient health status data
■ an organized, systematic, ongoing process of collecting, validating, and clustering data
■ collecting different types of data about the individual’s past and present health
■ assessing factors influencing health and well-being, including (see Fig. 1-1)
2. Secondary prevention encompasses early screenings and detection of disease and treatment of diseases (e.g., colonoscopy to screen for colon cancer and medications to treat a curable illness).
3. Tertiary prevention encompasses the restoration of health after illness or disease has occurred (e.g., rehabilitation program for stroke patients).
■ TIP Health insurances and the individual’s finances may influence the ability to have health promotion screenings.
□ physical health
□ behavioral aspects of health
□ spirituality
□ social factors
□ economic-political aspects of health
□ cultural variations
□ life span and developmental considerations
■ Performing a physical examination.
COMMUNICATION SKILLS
■ Health assessment requires essential therapeutic communication skills to obtain information about the individual.
■ The purpose of communication is to exchange information about the patient’s health and well-being (Fleischer et al., 2009).
■ Communication facilitates a patient-centered relationship.
FUTURE OF HEALTH CARE
On March 23, 2010, Congress passed and the President of the United States signed into law comprehensive healthcare legislation. The Patient Protection and Affordable Care Act (PPACA), also known as “Obamacare,” provides higher-quality, safer, and more affordable and accessible care (Institute of Medicine, 2011). All individuals have the ability to buy health insurance through the health insurance marketplace. The PPACA’s goal is to improve accessibility to health care, keep individuals healthy, help patients manage their chronic conditions better, and prevent illness. The healthcare system needs nurses to have strong assessment skills, educate patients, and advocate for patients.
Nurses have a leading role in being advocates for their patients and providing compassionate care. The new Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) Provision 3 states the nurses promotes, advocates for, and protects the rights, health and safety of the patient. The ANA proclaims that every nurse is individually responsible and accountable for maintaining professional competence and must perform safe practice (ANA, 2015). Nurses need to listen carefully to each patient’s self-report and be cognizant of the smallest details. Registered nurses are instrumental and have the knowledge and skills to thoroughly assess individuals in any practice setting.
Nurses need to maintain currency in their profession. Best practice assessments and instruments have been validated by research. Nursing
■ Interpersonal communication skills and the ability of the nurse to communicate with patients, family members, and the interdisciplinary healthcare team are essential in health assessment. Communication and interviewing techniques will be discussed more in Chapter 2.
research and evidence-based practice guide our assessments and clinical decisions to provide safe and effective care. Since the 1990s, there has been a paradigm shift to use evidence-based practice to guide nurses to make clinical judgements and use best practice protocols to provide optimum care to patients (Hoop & Rittenmeyer, 2012). The significance of evidence-based practice may be viewed in Box 1-2.
BOX 1-2 Significance of Evidence-Based Practice
• It has international importance.
• There are large, regional variations in use of evidence-based practices.
• There is rapid development of research but slow adoption of evidencebased practices.
• Only about half of all patients in the United States receive recommended care.
• There is a 28 percent improvement rate in patient outcomes when nurses use intervention based on research versus standard care.
• “Pay-for-performance” requires that evidence-based practices are used.
• “Know-do gap” keeps patients from receiving the best care.
(Hopp & Rittenmeyer, 2012)
Interviewing the Patient for a Health History 2
INTRODUCTION
Interviewing and obtaining the health history are the key components to obtain baseline information about a patient. As early as 1953, Hildegard Peplau, a nursing theorist, emphasized the nurse-patient relationship as the foundation of nursing practice. Nurses interview patients in many different environments, including hospitals, long-term care settings, homes, clinics, and community centers. Communication and interviewing techniques are acquired skills (Varcarolis, 2011) and should be practiced. The process begins a therapeutic partnership between the nurse and the patient. During an interview, the nurse initiates the nurse-patient relationship and the patient relinquishes his or her independent role to that
THERAPEUTIC COMMUNICATION
Interviewing a patient requires therapeutic communication skills. Communication is a complex process that is influenced by a variety of personal, environmental, cultural, and social factors. It is the act of transmitting information effectively and a process of creating shared understanding (Barker, 2013). Nurses need to offer their presence, mutual respect, caring, and understanding during every patient encounter. As a healthcare provider, the nurse recognizes that each patient is unique and has feelings and beliefs.
Nurses are responsible for gathering vital health and personal information about the patient. During the patient encounter, the nurse needs to
of a dependent role. The exchange of information, feelings, and concerns takes place during the assessment process. The nurse should be sensitive, nonjudgmental and genuine and demonstrate professionalism.
SENC Patient-Centered Care Privacy and confidentiality must be maintained and respected during the entire patient encounter. In April 2003, the Health Insurance Portability and Accountability Act (HIPAA) federally regulated and created a law to maintain confidentiality for all personal health information (U.S. Department of Health and Human Services, 2003).
focus the direction of the interview to make sure all vital information is obtained and a clear understanding of the patient’s concerns is acquired. Therapeutic communication encompasses the following dimensions for a patient-centered assessment:
■ Empathy and compassion are a deep awareness of and insight into the feelings, emotions, and behavior of another person and their meaning and significance (Venes, 2013), and identifies a patient’s feelings and concerns.
■ Unconditional regard means respecting and accepting a patient as a unique individual.
communicate in different ways. While verbal and written communication skills are important, research has shown that nonverbal behaviors make up a large percentage of our daily interpersonal communication (Cherry, n.d.). Communication is said to be 10 percent to 20 percent verbal and 80 percent to 90 percent nonverbal (Varcarolis, 2011). The following are nonverbal visual cues to be aware of during an interview:
■ physical appearance
■ body language
■ facial expression
■ eye contact
■ gestures
■ facial grimacing
■ tone of voice
■ nonverbal sounds such as crying and moaning.
■ TIP Remember that both you and the patient convey nonverbal body language. During the interview, health history, and assessment be mindful of your body language.
CULTURAL CONSIDERATIONS Russians do not appreciate gestures such as standing with hands inserted in pockets, arms crossed over chest, or slouching postures when being interviewed. Until trust is established, many Russians are aloof when speaking with healthcare providers (Purnell, 2014).
COMMUNICATION TECHNIQUES
Effective Communication
Therapeutic communication will facilitate a therapeutic exchange between a patient and a nurse. Nurses must develop and refine communication skills to assess patients. While assessing patients, nurses need to be open to receive information in a nonjudgmental way. There are some helpful strategies that may be able to assist you to elicit or clarify information throughout the interview.
SENC Patient-Centered Care Some experiences may be difficult or painful for a patient to discuss. Ask permission to ask sensitive questions.
Effective communication includes the following:
■ Be clear, concise, and honest in your communication.
■ Be sure that you have a shared understanding of the patient’s report, problems, and concerns.
■ Avoid medical terminology that may not be understood.
■ Keep your questions simple for clear understanding.
■ Ask one question at a time, and wait for the patient to respond.
■ Listen attentively and maintain eye contact (if culturally appropriate).
■ Do not interrupt the patient while he or she is talking.
■ Avoid taking excessive notes during the interview.
■ Display nonverbal body language that says you are interested in hearing the patient’s story (be cognizant of your posture, maintaining eye contact, and hand gestures).
■ Always ask permission before touching a patient; take into account cultural considerations.
Some effective communication techniques include:
■ Active listening: Pay close attention to the patient’s report and nonverbal cues; maintain good eye contact and express a willingness to listen.
■ Active observing: Concentrate on what you hear and see during the interview.
■ TIP Nurses should document what they see or observe during the interview such as the patient crying during the interview while discussing the recent loss of a spouse.
■ Broad opening questions: Will allow the patient to report more spontaneous information and tell you their story. An example is, “What can I do for you today?”
■ Clarification: Obtain clarification if the patient does not clearly express the problem or issue and you are confused about what the patient is saying to you. An example is, “I did not understand what you meant when you said the rash comes and goes. Can you explain what ‘comes and goes’ means?”
■ Confrontation: Give the patient honest and respectful feedback about what you see or hear that is inconsistent with what the patient is telling you. An example of this is, “You told me that you do not have a drinking problem but you stated that you were arrested for drinking under the influence 3 months ago? Can we talk about how much alcohol you drink on a daily basis?”
SENC Patient-Centered Care Never sound angry or judgmental when confronting a patient; be cognizant of your tone of voice and nonverbal body language.
■ Empathy: Identify, understand, share, and accept the patient’s feelings. Empathy is caring about and for the patient as you are speaking together. An example of an empathetic response is, “I am sorry to hear that you have been in pain for this long. How has the pain affected your daily life?”
■ Respect: Be respectful of what the patient is saying and feeling. An example of being respectful is, “This has been a difficult time for you
since your husband has been in jail. You are showing great strength in continuing to care for your children.”
■ Exploring: Encourage the patient to give you more details. An example is, “Tell me more about the pain in your back.”
■ Facilitation: Use simple verbal statements or words to encourage the patient to continue to tell the story. Use statements like “uh-huh,” “Mm” or “And then?”
■ Focusing: Ask specific questions to collect and clarify data that the patient may not be stating during the interview. An example of a focused question is, “How many stairs can you climb before you feel short of breath?”
■ Reflecting/Stating the Observed: Repeat the patient’s words specifically to encourage elaboration of the patient’s self-report; this encourages more discussion. An example of reflection is Patient: “I cannot believe that I did not go for my mammogram and now I may have breast cancer.”
Nurse: “You sound upset. Are you angry that you did not go for your mammogram?”
■ Transitional statements: Use transitional statements to help redirect the interview to another significant area. An example of a transitional statement is, “Now, I would like to discuss your family history.”
■ Silence: Refrain from speaking; planned absence of verbal remarks allows the patient and the nurse to think over or feel what is being discussed. If silence does not prompt a response within 5 to 10 seconds, the interviewer should try another skill as prolonged silence may make the patient feel uncomfortable (Fortin, Dwamena, & Smith, 2012). An example of a question you might ask is, “You appear to be quiet. Is there anything you would like to talk about?”
■ Summarizing: State a brief summary at the end of the interview; this allows for clarification and accurate data of the patient’s history or problem. An example of initiating a summary is “Let me summarize the important points.”
Communicating With a Patient With a Language Barrier
A patient with a language barrier does not understand or speak English.
■ TIP If an interpreter is not available, the nurse should have a list of certified medical interpreters who can be available by phone.
■ Ask the patient if he or she understands English; if the response is negative, ask the patient’s preferred language.
■ Use your resources to find a trained face-to-face interpreter; a professional interpreter will be able to convey objective information between you and the patient; ask the patient about any preference for a same-gender interpreter.
■ Explain to the interpreter the purpose and goals of the assessment.
■ The interpreter should explain the purpose and goals of the assessment to the patient.
■ During the interview and assessment, look at the patient, not the interpreter.
■ Ask simple and clear questions; provide time for the patient to ask questions.
■ TIP It is not recommended to use family members during an assessment to interpret for the patient for several reasons. A family member may
■ Be subjective when giving information.
■ Purposely omit information.
■ Give his or her own opinion.
■ Answer for the patient.
■ The patient may not want the family member to know the truth.
Communicating With Patients With Low Health Literacy
Implementation of the Affordable Care Act (ACA) of 2010 has resulted in significant changes to the U.S. healthcare system. Among its many provisions, the ACA extends access to healthcare coverage to millions of Americans who have been previously uninsured. Many of the newly eligible health insurance consumers are individuals of low health literacy.
Patients with low health literacy may have difficulty understanding; many patients cannot read.
■ TIP Many patients are embarrassed to let you know that they cannot read. To assess whether a patient can read, give the patient a newspaper or a patient instruction sheet to read to you.
■ Speak in very simple and clear language.
■ Ask the patient if he or she understands your questions.
■ Use pictures or diagrams, if necessary.
Cultural Considerations
A patient’s culture can influence the interview process. A patient may have many different definitions and perceptions of health and illness. The patient’s comfort level in regard to disclosing private issues with unfamiliar people, having physical closeness with unfamiliar people, involving significant other or family in the assessment process, and being addressed by first name varies among age, socioeconomic, and ethnic groups (O’Brien, Kennedy, & Ballard, 2008).
■ Respect the patient’s needs and preferences for modesty, uncovering only those parts of the body necessary for examination and treatment.
■ Many cultures and religions have restrictions on touching, distance, and modesty, which may be affected by providers of the opposite sex or staff that are younger or older than the patient (The Joint Commission, 2010).
Some examples of cultural considerations are:
■ American Indian/Alaskan Native Heritage: Same-gender healthcare providers are required for intimate care (Purcell, 2014).
■ Islamic culture and some religious Jews: Shaking hands with the opposite gender is viewed as culturally inappropriate (Fortin, Dwamena, Frankel, & Smith, 2012).
■ People with French, British, and African backgrounds: Avoidance of eye contact by another person might be interpreted as disinterest (Varcarolis, 2010).
■ American Eskimos: Silence is preferred and they may wait for several minutes before replying to a simple statement or greeting. If American Eskimos sense some intolerance from the nurse toward the use of silence, they may feel dominated and inferior, so the nurse should be cautious and not try to fill any silences (Dayer-Berenson, 2011).
■ Cambodians: Be mindful of spacing and avoid prolonged eye contact; it is inappropriate to stare (Dayer-Berenson, 2011).
■ Chinese: Most speak in a moderate to low voice tone and consider Americans to be loud. Be aware of your tone of voice when interacting with Chinese patients (Purcell, 2014).
■ German Heritage: Feelings are considered private and difficult to share. Sharing one’s feelings with others often creates a sense of vulnerability or is looked on as evidence of weakness (Purnell, 2014).
■ Italian Americans: They tend to over-report symptoms or report their symptoms in a very dramatic manner (Dayer-Berenson, 2011). Language problems can face the nurse when the elderly or a new Italian immigrant seeks medical care. Cultural modesty may impact the ability to get adequate or complete answers to medical questions, even when an interpreter is used (Dayer-Berenson, 2011).
Types of Questions Used When Interviewing
Communication is an exchange of information. To gather information, there are two types of questions you can ask the patient during the interview.
■ Open-ended questions allow the patient to express thoughts and encourage verbalization; this type of question allows the nurse to explore the focused topic more broadly. Patients are able to give you information in their own words. Some examples of open-ended questions and statements are:
□ “How do you remember to take all of your medications?”
□ “Tell me more about how you are feeling.”
□ “What brings you to the clinic today?”
■ TIP Information that the patient gives you is subjective data; use quotes if you are using the patient’s exact words in your documentation. An example would be that the patient states: “I am so worried that I may have cancer.”
■ Closed-ended questions clarify and focus on specific problems, limit responses, and are usually answered with one-word responses such as “yes” or “no.”
■ During the health history, each inquiry should start with open-ended questions or statement to elicit patient information followed by closed-ended questions to gather specific details. An example would be, “Tell me about your daily eating patterns.” Did you ever have to try to lose weight?”
THE INTERVIEW
The health history interview is a conversation with a purpose (HoganQuigley et al., 2012). It is a complex process that requires astute communication and observational skills. The nurse should prepare to interview the patient. Steps to prepare for the interview include the following:
■ If available, review the patient’s record.
■ Organize your thoughts.
■ Review how you will collect the data.
■ Identify the goals for the interview.
■ TIP Patient reports specific symptoms are “pertinent positives.” Patient denies specific symptoms are “pertinent negatives.” These reported or denied symptoms are documented in the ROS. An example would be: “Reports nasal congestion, sneezing and watery eyes. Denies sinus headache/pressure, postnasal drip, and rhinorrhea.”
Types of Health History and Sources
There are three types of health histories:
1. Comprehensive health history: A comprehensive health history looks at the whole patient and reviews all body systems; this health history takes time. For example, reviewing the patient systems from head to toe is routinely done during an annual examination.
2. Focused or problem-based health history: This type of health history focuses specifically on an acute problem or symptom that the patient is experiencing. Patients being seen in urgent care or the emergency room will have this type of health history. For example, if a patient is having difficulty breathing, the health history would focus on the respiratory and cardiac systems.
3. Follow-up history: This history occurs after a patient has been seen; it concentrates on new data since the last history. For example, a patient was originally treated and worked up for heart palpitations and is being seen two weeks later to evaluate the treatment.
Data are collected from two types of sources:
1. Primary source is the patient who is being interviewed and assessed. 2. Secondary sources are family members, significant others, or medical records of the patient.
□ Secondary sources may be used if the patient has a sensory deficit or cannot communicate information due to a physical or psychological/cognitive disability.
Reliability of the source means the patient is communicating clear and accurate information and has the ability to recall past medical information. It is important to determine whether the patient is reliable. This may be done by asking patients questions that you can confirm the answers to, such as “What is your date of birth?”
Some patients may be unreliable because of decreased cognitive ability or mentation. Secondary sources will be needed to provide information for the health history. If this occurs, document “Patient is unreliable; report by patient’s son.” The information that the patient tells you during the health history will provide valuable information for the nurse when progressing to perform the health assessment. This interview process takes time and requires your full attention, good therapeutic communication skills, and building rapport and trust with the patient.
Taking the Health History 3
INTRODUCTION
The health history is an important part of the health assessment because it provides essential and critical sharing of information about the patient’s past and present health. As a nurse, you will assess the patient using a holistic approach. Every patient is unique and has his or her own personal beliefs about health and illness that are influenced by their culture and their perception of health.
THE HEALTH HISTORY
The health history records subjective and essential data. Subjective data are pieces of information reported by the patient. Purposes of the health history include:
■ Document a database of past and present health including a medical history of medical problems, hospitalizations, and surgeries.
■ Document family history.
■ Identify psychosocial factors influencing health and well-being.
■ Identify self-care and health promotion practices.
■ Determine strengths and weaknesses of the patient.
■ Identify teaching needs.
■ Identify discharge needs or case management referrals.
SENC Patient-Centered Care During the health history, some of the questions may be uncomfortable for the patient to answer because the patient does not know how you will react or feels like you may judge them. Reassure the patient that you are here to help and the information will remain confidential.
Reason for Seeking Care
The reason for seeking care is synonymous with the chief complaint or the presenting problem. The reason for seeking care may focus on:
■ the history of present health (patient is here for an annual physical examination)
■ illness (e.g., general fatigue and weakness)
■ the presenting symptom(s) (e.g., cough and congestion).
Ask the patient:
■ What brings you here today?
□ Specific details are required to attain necessary information about the patient and his or her health-related concerns. Open-ended questions will invite the patient’s story. After the patient has finished speaking, you may have to explore the patient’s self-report or ask more focusing questions.
