Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies.
Case
• 55-year-old Asian female living in a high-density poverty housing complex.
• Pre-school aged white female living in a rural community.
- What are the barriers to interpersonal communication?
- What are the procedures and examination techniques that will be used during the physical exam of your patient?
- Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
Full Answer Section
Barriers to Interpersonal Communication and Cultural Considerations
1. Barriers to Interpersonal Communication:
- Language: If the patient does not speak English fluently, language barriers can hinder communication and understanding.
- Cultural Differences: Cultural differences in communication styles, values, and beliefs can lead to misunderstandings and misinterpretations.
- Stereotypes and Biases: Prejudices or stereotypes can affect communication and create barriers to trust.
- Differences in Education and Socioeconomic Status: Disparities in education and socioeconomic status can impact communication styles and understanding of medical terminology.
2. Procedures and Examination Techniques
For the 55-year-old Asian female:
- Cultural Considerations: Respect cultural norms and practices, such as avoiding eye contact or touching certain body parts.
- Language Interpretation: If necessary, use a qualified medical interpreter to ensure effective communication.
- Cultural Competency: Demonstrate knowledge and understanding of Asian cultures and traditions.
- Examination Techniques: Adapt examination techniques to the patient's comfort level and cultural preferences.
For the pre-school aged white female:
- Age-Appropriate Techniques: Use age-appropriate language and explanations to make the examination less intimidating.
- Distraction Techniques: Employ distractions, such as toys or games, to help the child relax during the examination.
- Parental Involvement: Encourage parental involvement and support throughout the examination.
3. S.O.A.P. Approach for Documentation
- Subjective: Document the patient's subjective complaints, including symptoms, history of present illness, and past medical history.
- Objective: Record the objective findings of the physical examination, including vital signs, general appearance, and specific findings related to the patient's symptoms.
- Assessment: Provide a diagnosis or differential diagnosis based on the subjective and objective findings.
- Plan: Outline the treatment plan, including medications, referrals, and follow-up appointments.
This approach ensures that patient data is documented in a clear, concise, and organized manner, facilitating communication and continuity of care.