Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021).

 Bates' guide to
physical examination and history taking (13th ed.). Wolters Kluwer.

 Chapter 1 Approach to the Clinical Encounter

 Chapter 2 Interviewing, Communication, and Interpersonal Skills
 Chapter 3 Health History
 Chapter 4 Physical Examination
 Chapter 5 Clinical Reasoning, Assessment, and Plan
 Chapter 7 Evaluating Clinical Evidence

   Foundations of Health Assessment

Foundations of Clinical Proficiency

The techniques of physical examination and history taking that you are about to learn to
embody the time-honored skills of healing and patient care. Gathering a sensitive and
nuanced history and performing a thorough and accurate examination deepen your
relationships with patients, focus your assessment, and set the guideposts that direct
your clinical decision making. The quality of your history and physical examination lays
the foundation for patient assessment, your recommendations for care, and your
choices for further evaluation and testing. As you become an accomplished clinician,
you will continually polish these important clinical skills.

Evidence-based Assessment
Gathering data through interviews and physical assessments provides information
required for clinical reasoning. Diagnostic reasoning goes a step further and applies a
scientific method to assist in analyzing data. Using the diagnostic reasoning model, the
practitioner will be alerted to specific cues that lead to various differential diagnoses
(Swartz, 2014). Further assessment will provide additional data that supports or does
not support each of the differential diagnoses and leads to the final diagnosis. The
novice practitioner will require much more time and guidance to reach a final diagnosis
than a proficient or expert-level practitioner.
Part of applying the diagnostic reasoning process requires that data be prioritized based
on the urgency of the signs or symptoms. For example, immediate priority must be
given to signs or symptoms that reflect life-threatening issues, while other signs and
symptoms might be assigned a secondary priority even though they are urgent until the
emergent issues are addressed. The lowest level priority issues are those that don't risk
life and don't have a high likelihood of escalating in severity.
The trend towards evidence-based practice (EBP) within healthcare, including nursing,
has led to the growth of evidence-based assessment (EBA) (Jarvis, 2016). The focus of
EBP is to provide an individual with the best and most current treatment available. In
order to achieve the goal of EBP, the use of EBA is necessary. Nurses are life-long
learners and must continually update their knowledge and skill set to ensure they are
providing the best and most current standard of care, including the best and most
current standard of assessment.
For example, 40-50 years ago, it was not common for nurses to auscultate heart or
breath sounds or to have a working knowledge that allowed them to analyze the data
gathered. It is not considered a standard of care for nurses at all levels to auscultate
heart and breath sounds and to analyze the data gathered on a routine basis. Advanced
practice nurses must possess superb assessment and diagnostic reasoning skills to
meet the standard of care and must be alert to the continued evolution of the standard
of care that results from EBP.

The Health History and Interview

Determining the Scope of Your Assessment
There are two types of patient presentations: a comprehensive assessment and a
focused or episodic visit. You will adjust the scope of your history and physical
examination to the situation at hand, keeping several factors in mind: the magnitude and
severity of the patient's problems; the need for thoroughness; the clinical setting—
inpatient or outpatient, primary or subspecialty care; and the time available. Skill in all
the components of a comprehensive assessment allows you to select the elements that
are most pertinent to the patient's condition.
For patients you are seeing for the first time in the office or hospital, you will usually
choose to conduct a comprehensive assessment, which includes all the elements of the
health history and the complete physical examination. An episodic visit is an office visit
where the patient will have a chief complaint such as cough, abdominal pain, sore
throat, etc. or a follow-up for a chronic illness. Your history and physical will be much
more focused on the chief complaint as you begin diagnosis and management. Patients
that present for a complete history and physical examination may not have a chief
complaint and therefore your history and subsequent physical examination will need to
be much more detailed as you focus on primary care.
The comprehensive examination does more than assess body systems. It is a source of
fundamental and personalized knowledge about the patient that strengthens the
clinician-patient relationship. Most people seeking care have specific worries or
symptoms. The comprehensive examination provides a complete basis for assessing
these concerns and answering patient questions.

Basic Interviewing Techniques

There are a variety of interviewing techniques that can be effective. Knowing when to
apply each technique will result in the most effective responses. These skills require
practice. Over time you will learn to select the techniques best suited to the ever-
changing dynamics of human behavior in your patient relationships. Key among these
techniques are active listening and empathy, the golden links to a therapeutic alliance.

Basic Interviewing Techniques

Basic interviewing techniques include:

 Active listening
 Empathic responses
 Guided questioning
 Nonverbal communication
 Validation
 Reassurance
 Partnering
 Summarization
 Transitions
 Empowering the patient

Complete the exercise by matching the interviewing technique with its description. The
basic techniques reviewed in the exercise are used throughout the interview.
Basic Interviewing Techniques
Transcript
Basic Interviewing Techniques
Read each slide carefully and thoroughly before answering. Then, select the BEST
answer from the choices provided.

 Active listening:

Active listening means closely attending to what the patient is communicating,

connecting to the patient's emotional state, and using verbal and nonverbal
skills to encourage the patient to expand on his or her feelings and concerns.

 Empathic responses:

Empathy has been described as the capacity to identify with the patient and feel
the patient's pain as your own, then respond in a supportive manner.

 Guided questioning:

Guided questions show your sustained interest in the patient's feelings and
deepest disclosures and allows the interviewer to facilitate full communication,
in the patient's own words, without interruption.

 Nonverbal communication:

Nonverbal communication includes eye contact, facial expression, posture,

head position and movement such as shaking or nodding, interpersonal
distance, and placement of the arms or legs—crossed, neutral, or open.

 Validation:

Validation helps to affirm the legitimacy of the patient's emotional experience.

 Reassurance:

Reassurance is an appropriate way to help the patient feel that problems have
been fully understood and are being addressed.

 Partnering:

When building rapport with patients, express your commitment to an ongoing

relationship.

 Summarization:

Giving a capsule summary of the patient's story during the course of the
interview to communicate that you have been listening carefully.
  Transitions:

Inform your patient when you are changing directions during the interview.

 Empowering the patient:

Empower patients to ask questions, express their concerns, and probe your
recommendations in order to encourage them to adopt your advice, make
lifestyle changes, or take medications as prescribed.

The Interview
The purpose of the interview is to gather information about the chief complaint or
presenting problem as well as the health history of the individual. A successful interview
balances time and information and a successful interviewer is able to maintain focus on
key issues while helping the patient to feel at ease and unrushed. Extracting the most
pertinent data in the least amount of time is the hallmark of the expert practitioner. The
expert interviewer is also able to make minimal notes during the interview while
retaining accuracy in documentation of the information when the interview is completed.
At the beginning of the interview, greet the patient and establish rapport. Discuss the
agenda for the interview and invite the patient's story. Remember to explore the
patient's perspective as well as identify and respond to emotional cues. During the
interview, the patient will respond to a variety of questions. The response to the
questions is important, but so is the way the patient responds. For example, do they
have problems remembering information that should be easy to recall for the average
person or do they slur their words? The interview is also a time for assessment of the
patient's mental status, including long and short term memory, as well as their
reasoning abilities. Expand and clarify the patient's story so that you may better
generate and test diagnostic hypotheses following the integration of physical
examination findings. As you elicit the patient's story, you must diligently clarify the
attributes of each symptom, including context, associations, and chronology.

Subjective Versus Objective Data

As you acquire the techniques of history taking and physical examination, remember the
important differences between subjective information and objective information,
summarized in the table below. Symptoms are subjective concerns, or what the patient
tells you. Signs are considered one type of objective information, or what you observe.
Knowing these differences helps you group together the different types of patient
information. These distinctions are equally important for organizing written and oral
presentations about patients into a logical and understandable format.

Subjective Versus Objective

  Subjective: Apparent only to person affected; includes client’s perceptions, feelings,
thoughts, and expectations. It cannot be directly observed and can be discovered only
asking questions.  
 Objective: Detectable by an observer or can be tested against an acceptable standard;
tangible, observable facts; includes observation of client behavior, medical records, lab
and diagnostic tests, data collected by physical exam.  

In the following drag and drop learning activity, separate the subjective data from
objective. 

Subjective Data Versus Objective Data

Subjective Data Versus Objective Data (Links to an external site.)

Transcript

Examples of Subjective Data:

 Lower back pain

 Fatigue
 Stomach cramps
 Immunization history
 Weight gain

Examples of Objective Data:

 Heart rate
 Blood pressure
 Lung sounds
 Wound appearance
 Ambulation description

The Health History

The health history interview is a conversation with a purpose. As you learn to elicit the
patient's story, you will draw on many of the interpersonal skills that you use every day,
but with unique and important differences. In social conversation, you freely express
your own views and are responsible only for yourself. In contrast, the primary goals of
the patient interview are to listen and to improve the well-being of the patient through a
trusting and supportive relationship.
Obtaining an accurate history is the critical first step in determining the etiology of a
patient's problem. A large percentage of the time, you will actually be able to make a
diagnosis based on history alone. The value of the history, of course, will depend on
your ability to elicit relevant information. Your sense of what constitutes important data
will grow exponentially in the coming years as you gain a greater understanding of the
pathophysiology of disease through increased exposure to patients and illness.
However, you are already in possession of the tools that will enable you to obtain a
good history. That is, an ability to listen and ask common-sense questions that help
define the nature of a problem. It does not take a vast, sophisticated fund of knowledge
to successfully interview a patient. In fact, seasoned clinicians often lose sight of this
important point, placing too much emphasis on the use of testing while failing to take the
time to listen to their patients. Successful interviewing is for the most part dependent
upon your already well-developed communication skills. A standard format for the
health history, obtained through interview, is to begin with the chief complaint which
involves developing the history of the chief complaint and then moving to the past
medical history (PMH).

Chief Complaint (CC)

Make every attempt to quote the patient's own words. For example, "My stomach hurts
and I feel awful." Although the information is coming from the patient, you are tasked
with determining if a relationship exists between multiple symptoms. In this example,
does the person "feel awful" because of their "stomach hurts", or are these separate
complaints? If unsure, ask the patient to clarify. Ultimately, one true chief complaint may
emerge. The remaining health history and plan of care will be contingent upon
determining the chief complaint early during the patient encounter. If patients have no
specific complaints, report their reason for the visit, such as "I have come for my regular
check-up" or "I've been admitted for a thorough evaluation of my heart."

History of the Present Illness (HPI)

The present illness is a complete, clear, and chronological description of the problems
prompting the patient's visit, including the onset of the problem, the setting in which it
developed, its manifestations, and any treatments to date. Each principal symptom
should be well characterized and should include the seven attributes of a symptom as
shown in this image. 
 Image Description

It is also important to query the "pertinent positives" and "pertinent negatives" drawn
from sections of the Review of Systems that are relevant to the Chief Complaint(s). The
presence or absence of these additional symptoms helps you generate the differential
diagnosis, which includes the most likely and, at times, the most serious diagnoses,
even if less likely, which could explain the patient's condition.

Past Medical History (PMH)

Past Medical History
Click on the interactive to learn more about past medical history.

Past Medical History (Links to an external site.)

Transcript

Past Medical History (PMH)

Click on each tile to explore more.
Medications: All medications should be noted, including name, dose, route, and
frequency of use. Also, list home remedies, nonprescription drugs, vitamins, mineral or
herbal supplements, oral contraceptives, and medicines borrowed from family members
or friends. Ask patients to bring in all their medications so that you can see exactly what
they take.
Allergies: Document specific reactions to medication, such as rash or nausea, as well
as allergies to foods, insects, or environmental factors.
Childhood Illnesses: These include measles, rubella, mumps, whooping cough,
chickenpox, rheumatic fever, scarlet fever, and polio. Also included are any chronic
childhood illnesses.
Adult Illnesses: Provide information relative to Adult Illnesses such as diabetes,
hypertension, hepatitis, asthma, and human immunodeficiency virus (HIV);
hospitalizations; number and gender of sexual partners; and risk-taking sexual
practices.
Surgical: Dates, indications, and types of operations.
Obstetric/Gynecologic: Obstetric history, menstrual history, methods of contraception,
and sexual function.
Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments.
Health Maintenance: Cover selected aspects of Health Maintenance, especially
immunizations and screening tests. For immunizations, find out whether the patient has
received vaccines for tetanus, pertussis, diphtheria, polio, measles, rubella, mumps,
influenza, varicella, hepatitis B virus (HBV), human papilloma virus (HPV),
meningococcal disease, Haemophilus influenzae type B, pneumococci, and herpes
zoster. For screening tests, review tuberculin tests, Pap smears, mammograms, stool
tests for occult blood, colonoscopy and cholesterol tests, together with results and when
they were last performed. If the patient does not know this information, written
permission may be needed to obtain prior clinical records.
Family History: Under Family History, outline or diagram the age and health, or age
and cause of death, of each immediate relative including parents, grandparents,
siblings, children, and grandchildren. Review each of the following conditions and
record whether they are present or absent in the family: hypertension, coronary artery
disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis,
tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness,
suicide, substance abuse, and allergies.
Personal and Social History: This should include the patient’s personality and
interests, sources of support, coping style, strengths, and concerns. It should include
occupation and the last year of schooling; home situation and significant others; sources
of stress, both recent and long-term; important life experiences such as military service,
job history, financial situation, and retirement; leisure activities; religious affiliation and
spiritual beliefs; and activities of daily living (ADLs).
Personal and Social History includes lifestyle habits that promote health or create risk,
such as exercise and diet, including frequency of exercise, usual daily food intake,
dietary supplements or restrictions, and use of coffee, tea, and other caffeinated
beverages, and safety measures, including use of seat belts, bicycle helmets, sunblock,
smoke detectors, and other devices related to specific hazards. Include sexual
orientation and practices and any alternative health care practices. Note tobacco use,
including the type. Cigarettes are often reported in pack- years (a person who has
smoked 11⁄2 packs a day for 12 years has an 18-pack/ year history). If someone has
quit, note for how long. Alcohol and drug use should always be investigated and is often
pertinent to the presenting illness.

Review of Systems (ROS)

A detailed review of the systems (ROS) follows the complete health history. There is no
"gold standard" for completing the ROS. There are dual objectives in ROS completion,
namely: (1) to obtain additional information about the patient's chief complaint and
history of present illness; and (2) to elicit symptoms of potential problems in uninvolved
systems (Phillips, Frank, Loftin, & Shepherd, 2017). A well-conducted ROS will help the
clinician identify cues that might have been missed in the health history. The most
effective way to complete the ROS is to ask yes or no questions and then follow up
when there is a response that indicates an abnormality with open-ended questions. This
method requires that the interviewer have a strong understanding of normal
expectations within the ROS as well as a keen ability to formulate appropriate questions
to focus on abnormalities when they are discovered. The abnormalities should be
processed in relation to the chief complaint and added to the data set being developed
around the chief complaint when appropriate. However, patients may present with
comorbidities that require the practitioner to develop multiple data sets simultaneously.
Organization and attention to detail are integral to conducting a ROS. Clinicians should
follow a head-to-toe approach and ask questions pertaining to organ or body systems. It
is important to remember that the ROS is subjective data ONLY, meaning it should
include what the patient or person providing the health history tells the clinician during
the interview. Objective data collected during the physical examination should be
documented separately in the health record. Care should be taken not to confuse
subjective with objective findings. Determining which body systems to include or
exclude on the ROS reflects the clinicians understanding of how body systems overlap
and symptoms interrelate. Therefore, you should ask questions from lists of symptoms
organized by body system. 
The following tutorial will help you to understand how to organize the ROS and what
constitutes pertinent findings.

Review of Systems video by Jessica Nishikawa

View the Review of Systems video by Jessica Nishikawa
 Review of Systems (Links to an external site.)
 Now, complete the following exercise to practice picking out the pertinent positive and
negative findings. Carefully listen to the health history and patient interview. You may
need to watch the video several times.

Bates' Video: Cough

View the Health History video up to the timestamp 5 minutes and 40 seconds.

Bates' Video: Cough (Links to an external site.)

Transcript

Most clinicians will have the SOAP note open on their tablet or computer screen as a
template to follow during the patient history. This allows you to stay organized and
comprehensive as you conduct the interview. Try listening to the video with the SOAP
note template open to become familiar with how to document relevant findings.

 SOAP Note Template ROS (Links to an external site.)

 Cough ROS Answer Key  (Links to an external site.) (Links to an external site.)

Problem List or Differential Diagnoses List

The ability to form a differential diagnosis is an art that develops through training and
practice. It is arguably a skill that forms the essence of a good clinician. A clinician must
review the patient's presenting complaint(s), history, and clinical examination findings in
order to accomplish this task. In general, differential diagnostic procedures are used by
clinicians to diagnose the specific disease in a patient, or, at least, to eliminate any
imminently life-threatening conditions.
It is important to understand the subtle differences between a problem list and
a differential diagnoses list. The differential diagnoses list is similar to, although
different from, the problem list.  The problem list can be defined as a list of current and
active diagnoses as well as past diagnoses relevant to the current care of the
patient.  Whereas the problem list includes all the medical, social, and psychologic
problems the patient has or may have, the differential diagnosis includes all the medical
diseases that may possibly explain the patient's chief complaint or principal problem.
For example, a patient with the chief complaint of vomiting blood and who has a
known history of migraines and diabetes, the problem list might read:

1. Hematemesis
2. Diabetes Mellitus
3. Migraine
4. Recent divorce
5. Poverty

On the other hand, the differential diagnoses for the chief complaint might read:

1. Peptic ulcer
2. Cirrhosis with bleeding esophageal varices
3. Acute hemorrhagic gastritis

A problem list is just that, an all-encompassing list of the patient's problems. A

differential diagnoses list is focused on providing an explanation for a specific complaint.
The problem list will likely include many of the same diagnoses as the differential list,
but also several more. In order to develop a differential list versus a problem list, you
must first identify the chief complaint. Each differential diagnosis should offer an
explanation or etiology for the same chief complaint.

Addressing Challenges
As an advanced nurse practitioner, you will develop a systematic method of conducting
your interview and completing a health history on an individual. This systematic method
will serve you well in many situations; however, there will be instances in which your
method may be challenged.
Typically, the very young and the very old will provide unique challenges. Patients that
have behavioral or cognitive dysfunction will also require alterations in how you conduct
your interview. There may be times that it is necessary to conduct a detailed mental
status exam of an individual while relying on others to provide the information usually
obtained from the patient. At other times, the individual may be able to provide the
history information, but you may question if the information provided is accurate and
reliable.
Data Collection and Documentation
Quality Patient Data
Almost all clinical information is subject to error. Patients forget to mention symptoms,
confuse the events of their illness, avoid recounting embarrassing facts, and may slant
their stories to what they believe the clinician wants to hear. Clinicians misinterpret
patient statements, overlook information, fail to ask "the one key question," jump
prematurely to conclusions and diagnoses, or forget an important part of the
examination, such as the funduscopic examination in a woman with headache, leading
to diagnostic errors. You can avoid some of these errors by following these tips to
ensure quality patient data:

Tips for Patient Data

Click on the interactive to learn more about tips for patient data.

Tips for Patient Data (Links to an external site.)

Transcript

 Ask open-ended questions and listen carefully to the patient's story

Follow a thorough and systematic sequence to history taking and physical examination
Keep an open mind toward both the patient and the clinical data
Always include "the worst-case scenario" in your list of possible explanations of the
patient's problem, and make sure it can be safely eliminated
Analyze any mistakes in data collection or interpretation
Confer with colleagues and review the pertinent clinical literature to clarify uncertainties
Apply the principles of evaluating clinical evidence to patient information and testing
 

SOAP note documentation may be a new concept and emerging skill for you. The
following tutorial videos were created to assist in your development. You may wish to
review these several times to increase your understanding and proficiency with using
the SOAP note to guide each patient encounter.
 
 
Below is a sample SOAP Note with completed documentation for a mock patient that
presents with the CC of sore throat.

 Sample SOAP Note

download

Documentation
A clear, well-organized clinical record is one of the most important adjuncts to patient
care. Your goal is a clear, concise, but comprehensive report that documents key
findings and communicates your assessment in a succinct and legible format to
clinicians, consultants, and other members of the health care team.
The SOAP note (an acronym for subjective, objective, assessment, and plan ) is a
method of documentation employed by health care providers to write out notes in a
patient's chart, along with other common formats, such as the admission note.
Documenting patient encounters in the medical record is an integral part of practice
workflow starting with patient appointment scheduling, to writing out notes, to medical
billing.
SOAP notes are commonly found in electronic medical records (EMR) and are used by
providers of various backgrounds. Prehospital care providers such as emergency
medical technicians may use the same format to communicate patient information to
emergency department clinicians. Physicians, physician assistants, nurse practitioners,
respiratory therapists, pharmacists, podiatrists, chiropractors,
acupuncturists, occupational therapists, physical therapists, school psychologists,
speech-language pathologists, certified athletic trainers (ATC), sports therapists, music
therapists, among other providers use this format for the patient's initial visit and to
monitor progress during follow-up care.