* Training of Instructor Skill Labolatory

TOPIC: COMMUNICATION SKILL’S: INFORMATION

GATHERING

Monday, 16 September 2019

Medical Fakulty, Universitas Wijaya Kusuma

Surabaya
Speaker : dr. Pandji Mulyono,Sp.PD KEMD
FINASIM
1. GENERAL OBJECTIVE
After finishing this skill practice, the student will be able to
perform good communication skill related to doctor patient
relationship.

2. SPESIFIC OBJECTIVE
At the end of skill practice, the student will be able to
perform interview to the patient in gathering data.
3. SYLLABUS DESCRIPTION

3.1 Expected Competencies

1. Student demonstrate good doctor patient relationship
2. Student demonstrate good communication skill in gathering data
from the patient

3.2 Topics
1. Communication skill
2. Information gathering

3.3 Methods
1. Presentation
2. Demonstration
3. Coaching
4. Self practice
5. Evaluation
3.4 Laboratory facilities
1. Skill laboratory
2. Trainers
3. Student learning guide
4. References
5. Standardized patient

3.5 Evaluation
1. Nodal point evaluation
2. OSCE
5. CHECKLIST
No Procedure Perfomance Scale
    0 1 2
A Initiating the Interview      
1 Greets patient      
2 Introduction      
 Introduced student’s self by name
and role
 Stated patient’s full name
 Made sure s/he used the patient’s
correct name
3 Ensured patient readiness and privacy;      
removed any barriers to
communication, minimized any noise
and distraction.
B Opens the Discussion (includes the      
following)
4 Explains and/or negotiates an agenda      
for the visit
5 Allows patient to complete opening      
statement without interruption
6 Asks “Is there anything else?” to elicit      
full set of concerns
      
C Gathers Information (includes the
following):
     
7 Used open-ended and closed
questions appropriately; moved
from OPEN TO CLOSED. Do not use
leading questions. (eg., “you don’t
have chest pain, do you?”
     
8 Used concise, easily understood
questions and comments; AVOIDED
MEDICAL JARGON; avoided
inappropriate vernacular.
     
9 Periodically summarize to verify
own understanding of what the
patient has said; invite patient to
correct interpretation or provide
further information.
D Building relationships-facilitating patient      

involvement
10 Demonstrate appropriate, non verbal      

behavior:
 
 Eye contact
 Facial expression
 Posture, positions, gesture, and other
movement
 Focal cues (rate, volume, tone, pitch)
11 If reads, write notes or use computer, does in      

a manner that does not interfere with dialog

or rapport
12 Demonstrate appropriate confidence      

13 Accept legitimacy of patients views and      

feeling; is not judgmental

14 Use empathy, to communicate understanding      

and appreciation of patients feeling or

situations; overtly acknowledge patients’
views and feelings. Provide support,
expresses concerns, understanding and
willingness to help; acknowledge coping
efforts and appropriate self-care; offer
partnership
Total      
Scale Performance achievement Comment

0 If student are doing the step less than Unsatisfactory

35% of the whole step precisely

1 If student are doing the step 35%-75% Fair

of the whole step precisely

2 If student are doing the step more Satisfactory

than 80% of the whole step precisely

For complete history taking please refer to following list
(related to problem)

No Information Gathering: Perfomance Scale

Content 0 1 2

1 IDENTIFYING DATA:      
   Date of interview      
(Write-up only)
 Time of interview
(Write-up only)
 Patient’s name
 Age
 Material Status
 Ethnic Backgroud
 Gender
 Gender (Write-up
only)
 Occupation
 Source and reliability of
history (Write-up only:
autoanamnesis/alloan
amnesis)
 
      
2 History of Present Illness (HPI). Must
elicit ALL of the following:
     
  a. Location;
b. Quality;
c. Severity;
d. First occurance;
e. Context;
f. Modifying factors;
g. Associated symptoms.
 
     
3 Asked patient questions relating to
his/her PAST MEDICAL HISTORY
     
  a. Allergies / Drug reactions
b. Medications
i. Current / recent Prescription
medications
ii. Current / recent Herbal medications
iii. Current / recent Over the counter
medications
c. Concurrent medical problems;
hospitalizations; surgeries; previous
injuries / trauma; previous illnesses
d. Growth and development / diet /
childhood diseases /immunizations
e. Toxins and / or industrial exposures /
occupational history
 
f. OB/GYN History
i. Menarche
ii. Menopause
iii. Childbearing
iv. Mammogram
v. Last pap smear
4 Asked patient questions      

relating to his/her FAMILY

HISTORY.

  a. Summary of ages and      

states of health or causes of

death of immediate family
b. Family members with
similar symptoms and signs
c. Presence of infectious
and / or chronic diseases in
family members
d. Family history of
psychological (depression,
anxiety, etc).
e. Family relationships
      
5 Asked about patient’s
SOCIAL HISTORY
     
  Who lives in your
Household
 
b.Social support (sources,
eg. Church, work,
friends, community,
temple)
 
c.Marital
status/committed
partnerships
 
d.Work
 
e.Recreation / exercise
f.Life satisfaction
g.Current stressors
6 Asked patient questions      

regarding lifestyle RISK

FACTORS, habits history
  a. Tobacco      

i. Current use
ii. Past use
b. Alcohol
i. Current use
ii. Past use 
c.Illegal drugs
i. Current use
ii. Past use
d. Sexual History
i. Currently sexually active
ii. Partners male / female /
both
iii. Practice safe sex
iv. Previous practices /
behaviors
e.Occupational hazards,
environmental exposures
      
7 Review of Systems.
Questioned patients
on AT LEAST 10 organ
systems

     
8 Asked additional
focused questions
about the system(s)
directly related to the
problem(s) identified
in the HPI.

     
  TOTAL
Scale Performance achievement Comment

0 If student are doing the step less than Unsatisfactory

35% of the whole step precisely

1 If student are doing the step 35%-75% Fair

of the whole step precisely

2 If student are doing the step more Satisfactory

than 80% of the whole step precisely

Thank You
For Your
Attention