00:01
Hello everyone and welcome to this video
on obtaining an accurate and an efficient
patient history.
00:07
My name is David Warren and I'm certified
as a family nurse practitioner, acute care
nurse practitioner, and emergency nurse
practitioner.
00:14
I really want to share with you my top
tips on obtaining histories from patients
and how that impacts our clinical decision
making process.
00:22
Number one, the foundation of quality care
always starts with a patient history.
00:28
An accurate and a complete history can
never be underestimated, especially in the
healthcare setting.
00:33
It helps us make those informed clinical
decisions, and it really helps us tailor
the treatment plan specifically to that
patient, and not just generalized based on
a diagnosis or a disease process.
00:47
Number two, the second point I want to
make to you is effective communication.
00:52
The importance and the significance of
effective communication skills in
obtaining a patient history cannot be
underestimated.
00:59
Whenever you go see a patient, you have to
develop trust with that patient.
01:04
In the emergency department setting, which
is where I work, it is extremely
challenging to go see a patient that
you've never seen before or may have never
seen before, and to develop that trust
with them in a matter of seconds.
01:15
And you have to be really good at that
or the patient will not be honest with you
in their patient history.
01:21
You need to do things like active
listening.
01:23
Are you listening to what the patient
says?
Are you allowing the patient to tell their
story?
Or are you interrupting every two seconds
to ask a question?
And we're all guilty of that.
01:32
But whenever you ask the patient, what is
going on today, start with an open-ended question.
01:37
What brings you to the emergency
department today?
Or what brings you into the clinic today?
And let the patient answer that question
in the way that they see fit.
01:44
Some will answer it in a shorter time
and others will answer it in a longer time
frame, but you need to stick to those
active listening techniques and open-ended
questions.
01:54
You really also need to create a
comfortable and non-judgmental
environment, and you need to encourage the
patient to share critical information, and
that can sometimes be challenging for
patients, especially whenever they come in
with things that they don't really want to
talk about.
02:09
but reiterating that making the best
decision for them and helping them on
their journey, they need to share the
critical information that you need to make
those decisions.
02:19
Number three, I want to highlight the
importance of digital tools and electronic
health records.
02:24
Before I go see a patient or before I ever
lay eyes on the patient, I will look in
the electronic health record to see if
they have prior visits.
02:32
Have they been to the emergency department
before?
And if so, why did they come and what was
the outcome?
Do they have chronic medical problems?
Are they followed by multiple specialty
providers?
Or have they never had care before?
Have they never been to the emergency
department before?
Is this their first visit to this
healthcare facility?
All of that plays a role in how I will
address the history to the patient or how
I will obtain a history from the patient.
02:59
If they have multiple specialty visits, I
will always bring that up.
03:02
When did you follow up with your
specialist last?
What did they say?
How are they managing your condition?
Versus if they don't have any chronic
medical problems, that will certainly
change how I approach the history.
03:13
And then I will look at the nursing notes
from today and the vital signs from today.
03:18
Why did they tell the nurse that they are
seeking care, or what are their current vital signs?
I look at all of that before I ever enter
the room to even talk to the patient.
03:28
I want to emphasize cultural
sensitivity and patient trust.
03:32
The importance of cultural competence in
obtaining an accurate patient history
can't be underestimated.
03:37
The patient may not look the same way that
you look.
03:40
They may not talk the same way that you
talk.
03:42
They may not have the same background or
the same educational history that you have.
03:47
And you have to be able to navigate that.
03:49
You have to be able to address the patient
the way that they want to be addressed.
03:52
And you have to talk to the patient the
way that they may want to be talked to.
03:56
And you have to earn the patient's trust.
03:58
Having those open discussions about a
patient's health really starts with being
culturally sensitive and developing their
trust.
04:05
Developing their trust may take some time.
04:07
You may only have a few seconds or a few
minutes, but you need to work at asking
those open-ended questions, presenting a
non-judgmental attitude, having those
non-verbal cues that will allow the
patient to know that they are safe opening
up to you and talking to you and providing
you with the necessary information so that
you can make medical decisions and a
treatment plan on their behalf.
04:28
I want to share with you
the red flags and the critical information
that you need to pick up on during patient
histories.
04:34
A lot of the times when you're talking to
a patient, they may give you inconsistent
things, or they may tell you something
that is blatantly false, or something that
you read in the prior medical record that
doesn't match up with today.
04:45
And you really need to be able to pick up
on those things and address them.
04:49
It really goes back to our prior point
about looking in the electronic medical
record at prior visits.
04:55
knowing what their prior history is and
knowing when the patient can be
inconsistent and being able to deal with
that and address it.
05:02
It's important to recognize that and to
call the patient out in the moment and not
wait until minutes or hours after to go
back and address it.
05:10
And of course that's not being judgmental it's stopping the
patient and saying hey I realized maybe
you said X Y & Z did you really mean that
or I read this in your medical record can
you tell me a little more about that using
those active listening techniques and
those open-ended questions to address
those red flags and that critical
information because if you are making
patient decisions or if you're making
diagnostic decisions upon false
information
that certainly will come back on you.
05:37
You need to be able to pick out those red
flags, those blatant lies that patients
may tell, and you need to address that in
real time with the patient.
05:46
Thank you so much for watching this video
on efficient and accurate patient history.
05:51
I hope you found the video helpful.