問診方法與技巧課件

問診方法與技巧ppt課件匯報人：xxx20xx-03-15RESUMEREPORTCATALOGDATEANALYSISSUMMARY目錄CONTENTS問診基本概念與重要性問診前準備工作問診方法與步驟常見癥狀詢問要點及注意事項溝通技巧在問診中應用心理社會因素在問診中考慮REPORTCATALOGDATEANALYSISSUMMARYRESUME01問診基本概念與重要性問診是中醫(yī)通過對話方式，向病人及其知情者查詢疾病相關情況，包括疾病發(fā)生、發(fā)展、現(xiàn)在癥狀、治療經(jīng)過等，以獲取診斷依據(jù)的方法。明確疾病診斷，了解病情輕重緩急，為制定治療方案提供依據(jù)，同時建立良好醫(yī)患關系，增強患者信任感。問診定義及目的問診目的問診定義問診在診斷中作用獲取詳細病史資料通過問診，醫(yī)生可以了解患者的既往病史、家族病史、生活習慣等，為診斷提供重要線索。輔助其他診法問診可以與其他診法（望、聞、切）相互印證，提高診斷的準確性。判斷疾病性質(zhì)與預后通過問診，醫(yī)生可以對疾病的性質(zhì)（寒熱虛實等）和預后做出初步判斷。以下附贈各項管理制度英文版（不需要可刪）急救藥品、器材管理制度:1.Rescuedrugsandequipmentshouldbe"fivefixed"(fixedquantityandvariety,designatedplacement,designatedpersonstorage,regulardisinfectionandsterilization,regularinspectionandmaintenance)and"twotimely"(timelyinspectionandmaintenance,timelyreceiptandsupplementation).Theitemisclearlymarkedandcannotbeusedarbitrarily.2.Thenecessaryrescueequipmentiscomplete,ingoodperformance,andinstandbycondition.3.Therescuedrugsarecomplete,withcleardruglabelsandnodiscoloration,deterioration,expiration,ordamage.Theyshouldbeplacedandusedintheorderofdrugexpirationdates(fromrighttoleft).4.Emergencydrugsanditemsforeachdepartment'srescuevehicleshallbeuniformlyequippedaccordingtorequirements.Specializedemergencydrugsanditemsmustbereviewedandapprovedbythedepartmentdirectortodeterminethetype,quantity,specifications,anddosagetobeequipped.Rescuevehiclesmustbeplacedindesignatedlocationsandmanagedbydesignatedpersonneltoensuresafetyandeaseofuse.5.Afterusingrescuedrugsandequipment,theyshouldbefullyreplenishedwithin24hours.Iftheycannotbereplenishedduetospecialreasons,theyshouldbenotedonthehandoverregistrationformandreportedtotheheadnurseforcoordinationandresolutiontoensuretimelyuseduringpatientrescue.6.Thereisaregistrationbookfortheprovisionofdrugsandequipment.Ensureconsistencybetweenaccountsandmaterials,andhandoverbetweenshifts.7.Managementofsealedrescuevehicles:Beforesealing,theheadnurse(ornurseincharge)andanothernurseshallcountthedrugsandequipmentaccordingtotheregistrationbookofdrugandequipmentequipment,verifytheiraccuracy,andsealthemwithaseal.Twopeopleshallsignandfillinthesealingtime.Nurseschecktheconditionofthesealsoncepershiftandcompletethehandover.Theresponsiblenursescheckonceaweek,andtheheadnurseandresponsiblenursesopenthesealsandinspectthedrugsandequipmentintheambulanceonceamonth,withrecordskept.8.Nonsealedrescuevehiclemanagement:Eachshiftshallcountthedrugsandequipmentaccordingtotheregistrationbookandcompletethehandover.Theresponsiblenurseshallinspectonceaweek,andtheheadnurseshallinspectonceeverytwoweeksandkeeprecords,ensuringthattheaccountsmatchthematerials.護理文書書寫制度:

1.Nursingstaffstrictlyfollowthelatestrequirementswhenwritingnursingmedicalrecords.2.Thecontentofnursingrecordsshouldbeobjective,truthful,accurate,timely,complete,andstandardized.3.Allnursingdocumentsshouldbewrittenwithablueblackorcarboninkpen.4.AllnursingdocumentsshouldbewritteninArabicnumeralsfordateandtime,withdatesinyears,months,anddays,usinga24-hoursystem,specifictominutes.5.WritingshoulduseChinese,medicalterminology,andcommonlyusedforeignlanguageabbreviations;Completerecorditems;Thetextisneat,thehandwritingisclear,andthelayoutisclean;Accurateexpression,fluentsentences,simpleandconcise:correctformatandpunctuation,notypos.6.Whenerrorsoccurduringthewritingprocess,doublelinethemonthewrongwords,keeptheoriginalrecordclearanddistinguishable,signthemodifier,indicatethemodificationtime,continuetowritethecorrectcontent,anddonotusescraping,sticking,paintingorothermethodstocoveruporremovetheoriginalhandwriting.Eachpageshouldbemodifiednomorethantwotimes,otherwisetheoriginalrecorderwillpromptlycopyagain(exceptformodificationsmadebysuperiors).7.Nursingrecordswrittenbyinternnurses,probationarynurses,orunregisterednursesshouldbereviewedandsignedbynurseswithlegalprofessionalqualificationsinthismedicalinstitution.8.Furthertrainingnursescanonlywritenursingdocumentsafterbeingrecognizedbythemedicalinstitutionreceivingthetrainingfortheirworkability.9.Superiornursingstaffhavetheresponsibilitytoreviewandmodifythewrittenrecordsofsubordinatenursingstaff.Whenmakingmodifications,reddoublelinesshouldbeusedtomarkerrors,writethemodifiedcontent,signandindicatethemodificationtime.10.Temperaturerecords,medicalorders,patientcarerecords,andsurgicalinventoryrecordsshouldbearchivedontime.良好的問診技巧可以讓患者感受到醫(yī)生的關心和專業(yè)性，從而提高患者滿意度。提高患者滿意度增強患者信心減少誤診漏診通過詳細詢問和解釋，醫(yī)生可以幫助患者建立對治療的信心，提高治療依從性。熟練掌握問診技巧，醫(yī)生可以更全面地收集病史資料，減少誤診和漏診的發(fā)生。030201良好問診技巧對患者影響REPORTCATALOGDATEANALYSISSUMMARYRESUME02問診前準備工作了解患者基本信息姓名、性別、年齡、職業(yè)等基本信息既往病史、家族病史等重要健康信息藥物過敏史、手術史等特殊醫(yī)療信息安靜、私密、整潔的診室環(huán)境親切、和藹、耐心的醫(yī)生態(tài)度適當?shù)闹w語言和面部表情，傳遞關愛和信任營造舒適溝通環(huán)境期望得到的幫助或解決方案，了解患者需求溝通解釋本次就診流程和注意事項，建立良好醫(yī)患關系主訴癥狀或問題，明確就診重點明確本次就診目標REPORTCATALOGDATEANALYSISSUMMARYRESUME03問診方法與步驟使用寬泛、開放的問題避免使用“是”或“否”回答的問題，而是讓患者自由表達。避免引導性提問確保問題中立，不暗示或引導患者做出特定回答。開放式提問技巧當需要獲取確切信息，如癥狀出現(xiàn)時間、頻率等時，使用封閉式提問。收集特定信息時在患者表達不清或信息模糊時，用封閉式提問進行澄清。澄清模糊信息時在已知信息充足，只需確認細節(jié)時使用。節(jié)省時間、提高效率封閉式提問時機把握123在患者回答后，重復或解釋以確保雙方理解一致。確認患者理解通過追問，引導患者表達出更深層次的感受和需求。挖掘深層信息當發(fā)現(xiàn)患者回答中存在矛盾或模糊之處時，及時澄清。澄清模糊或矛盾信息追問和澄清策略運用在問診過程中，不斷提煉和總結患者的關鍵信息。提煉關鍵信息將患者的問題和需求進行梳理，形成清晰的診療思路。梳理問題與需求在歸納總結后，向患者反饋并確認理解無誤，以確保信息準確傳遞。反饋與確認歸納總結能力培養(yǎng)REPORTCATALOGDATEANALYSISSUMMARYRESUME04常見癥狀詢問要點及注意事項發(fā)熱詢問發(fā)熱起始時間、熱度、持續(xù)時間、伴隨癥狀（如寒zhan、頭痛、乏力等），了解發(fā)熱原因（感染、非感染）及患者自我感知?？人栽儐柨人孕再|(zhì)（干咳、濕咳）、頻率、時間（晝夜差異）、伴隨癥狀（如咳痰、喘息、胸痛等），了解咳嗽原因（呼吸道疾病、心血管疾病等）及影響因素。發(fā)熱、咳嗽等常見癥狀詢問要點指導患者使用疼痛量表（如數(shù)字評分法、視覺模擬評分法），描述疼痛部位、性質(zhì)（鈍痛、銳痛、絞痛等）、程度、持續(xù)時間及影響因素。疼痛描述介紹疼痛評估工具（如疼痛日記、疼痛評分卡等），闡述疼痛對患者生活質(zhì)量的影響及疼痛控制的重要性。評估標準疼痛描述方法及評估標準介紹注意事項和誤區(qū)提示注意事項強調(diào)問診過程中的溝通技巧（如傾聽、引導、確認等），提醒患者提供準確、全面的癥狀信息，避免遺漏重要癥狀。誤區(qū)提示指出患者在描述癥狀時可能出現(xiàn)的誤區(qū)（如夸大、縮小、混淆等），提醒醫(yī)生注意甄別和核實，確保診斷的準確性。REPORTCATALOGDATEANALYSISSUMMARYRESUME05溝通技巧在問診中應用傾聽技巧設身處地地理解患者感受，用溫暖的語言回應。同理心表達鼓勵患者表達用開放式問題引導患者詳細描述癥狀和感受。保持眼神接觸、不打斷患者、用肢體語言表示關注。傾聽、同理心表達技巧反饋技巧重復或總結患者所述，以確保理解正確。確認信息準確性用封閉式問題核實關鍵信息，如癥狀持續(xù)時間、程度等。澄清模糊信息當信息不明確時，要求患者進一步解釋或提供更多細節(jié)。反饋、確認信息準確性方法03保持一致性