By Lynn S Bickley; Peter G Szilagyi; Barbara Bates
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Additional info for Bates' pocket guide to physical examination and history taking
Patient With Limited Intelligence. Patients of moderately limited intelligence usually can give adequate histories. Pay special attention to the patient’s schooling and ability to function independently. How far has the patient gone in school? If he or she didn’t finish, why not? Assess simple calculations, vocabulary, memory, and abstract thinking. For patients with severe mental retardation, obtain the history from the family or caregivers. Avoid “talking down” or using condescending behavior.
Sample Problem List Date Entered 8/30/08 Problem No. qxd 9/3/08 2:30 PM Page 37 C H A P T E R Interviewing and the Health History 3 The health history is a conversation with a purpose. Unlike social conversation, in which you express your own needs and interests with responsibility only for yourself, the primary goal of the clinician–patient interview is the well-being of the patient. The purpose of patient history taking is three-fold: to establish a trusting and supportive relationship, to gather information, and to offer information.
The ideal interpreter is a neutral, objective person trained in both languages and cultures. Avoid using family members or friends as interpreters: confidentiality may be violated. As you begin working with the interpreter, make questions clear, short, and simple. Speak directly to the patient. Bilingual written questionnaires are valuable. qxd 48 9/3/08 2:30 PM Page 48 Interviewing and the Health History G UIDELINES FOR W ORKING W ITH AN I NTERPRETER ● Choose a professional interpreter in preference to a hospital worker, volunteer, or family member.