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Running head: MEDICAL INTERVIEW
The Medical Interview
A medical interview is a therapeutic and diagnostic tool that is used by physicians to
assess the medical situation. It is a difficult skill that requires the use of both the emotional and
intellectual skills of the physician. Interviewing is a practical skill that can only be learnt through
practice. A medical interview is a conversation that is undertaken where the physician has clear
goals and objectives in his mind (Buchanan, 2015). Through medical interviews, the physician
can be able to collect information and influence the behaviors of the patient.
Documenting accurately and appropriately means that the physician records all the
relevant information accurately. An accurate and appropriate documentation, therefore, means
that the physician provides an accurate record of the care planning, treatment, and delivery. This
should be done after the involvement of the patient and preferably immediately after the
occurrence of an event. Good documentation is, therefore, a critical skill that is needed by
physicians as it can be used in court.
The documentation guidelines were created to outline the content for the record keeping
of the medical history, physical examination and decision making process. The documentation
guidelines vary due to the uniqueness of every situation. Abbreviations can cause many medical
errors in situations of misinterpretation. They are therefore very critical to patient safety and
should only be used when necessary in shortening long medical terms which cannot be otherwise
Subjective data refers to information according to the point of view of the patient also
referred to as symptoms. This may include; feelings, concerns, and perceptions that are usually
obtained through medical interviews. Objective data is measurable and observable data also
known as signs. This includes; physical examination, laboratory testing, and observation.
Clinical reasoning refers to the process where the physician collects information, process
it, understand the pa...
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