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Shadowhealth Interview Guide
Medical-Surgical Nursing I: Perspectives and Assessment of Care (NUR201)
The College of New Jersey
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PATIENT INTERVIEW GUIDE
Obtain pertinent demographic information (sometimes you already have this information from the chart) May not need to ask all of the information listed, especially if it is a quick interview Chief Complaint “What brings you here today?” History of Present Illness May not all be necessary, depending on the chief complaint; use judgment – may also need to elaborate beyond these questions Where it is located on the body (such as pain) o Does it radiate Timing o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o If intermittent, how long does it last, and how often does it occur? Quality (particularly important if pain) o Dull, sharp/knife‐like, achy, pressure, tightness, tingling, etc Severity or intensity What triggers the symptom o What were you doing when it started o What causes it to occur Alleviating / aggravating factors o What helps it o What makes it worse Any other symptoms that you have? Past Medical History If possible find out how long current illnesses have been going on, and obtain dates for any events It may not be necessary to ask every question, if not pertinent Childhood illnesses Adult illnesses o Include any recent illnesses (i. infection) Surgeries Hospitalizations Injuries Trauma Screening tests or exams Allergies Prompt with common allergies, if needed (aspirin, sulfa, penicillin) Make sure you include the reaction Also ask about seasonal, environmental, contact and food allergies
Current Medications Prescribed medications (also determine when started and if any doses have been changed recently) o Questions to ask about medications Name of medication Dosage and frequency / change in dosage (make sure you have correct units) The way the patient is actually taking it (don’t assume it’s the same as written) The reason the patient is taking the drug How long taking it Does the patient feel it is working Has the patient had any issues or side effects from it Compliance / remember or able to take it (can ask how the patient remembers to take it) o Remind of typically “forgotten” medications: Samples Birth control pills Creams/ointments Eye/ear medications Inhalers Recent / current antibiotics Clarify any PRN medications for frequency of use Over‐the‐counter medications o Herbal / natural products (including household remedies) o Vitamins Immunization status Family History May not always be important to ask this information (use judgment) Age/current health status of parents, siblings and grandparents (if applicable) Based on judgment could ask about similar symptoms or conditions in family Social History May not need to ask all of these (use judgment) Occupation Tobacco/Alcohol Illicit drugs Caffeine use (if applicable) Diet (especially if on a special diet; or should be on one but is not) Exposure (if applicable, such as with infections) Sexual partners (if applicable) Living situation Ability to perform activities of daily living (if applicable) Recreation Safety situations (i. abuse; if applicable) Review of Systems Typically asked as closed‐ended questions (yes/no); often will be filled out ahead of the visit May not need to ask all of these questions, especially if focused interview/examination‐ use your professional judgment
Shadowhealth Interview Guide
Course: Medical-Surgical Nursing I: Perspectives and Assessment of Care (NUR201)
University: The College of New Jersey
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