問診方法與技巧課件

問診方法與技巧ppt課件匯報(bào)人：xxx20xx-03-15RESUMEREPORTCATALOGDATEANALYSISSUMMARY目錄CONTENTS問診基本概念與重要性問診前準(zhǔn)備工作問診方法與步驟常見癥狀詢問要點(diǎn)及注意事項(xiàng)溝通技巧在問診中應(yīng)用心理社會(huì)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(duì)話方式，向病人及其知情者查詢疾病相關(guān)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(shí)建立良好醫(yī)患關(guān)系，增強(qiáng)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(xì)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(xí)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(zhǔn)確性。判斷疾病性質(zhì)與預(yù)后通過問診，醫(yī)生可以對(duì)疾病的性質(zhì)（寒熱虛實(shí)等）和預(yù)后做出初步判斷。以下附贈(zèng)各項(xiàng)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(hù)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(guān)心和專業(yè)性，從而提高患者滿意度。提高患者滿意度增強(qiáng)患者信心減少誤診漏診通過詳細(xì)詢問和解釋，醫(yī)生可以幫助患者建立對(duì)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(duì)患者影響REPORTCATALOGDATEANALYSISSUMMARYRESUME02問診前準(zhǔn)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(shù)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(dāng)?shù)闹w語言和面部表情，傳遞關(guān)愛和信任營(yíng)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(xiàng)，建立良好醫(yī)患關(guān)系主訴癥狀或問題，明確就診重點(diǎn)明確本次就診目標(biāo)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(dá)。避免引導(dǎo)性提問確保問題中立，不暗示或引導(dǎo)患者做出特定回答。開放式提問技巧當(dāng)需要獲取確切信息，如癥狀出現(xiàn)時(shí)間、頻率等時(shí)，使用封閉式提問。收集特定信息時(shí)在患者表達(dá)不清或信息模糊時(shí)，用封閉式提問進(jìn)行澄清。澄清模糊信息時(shí)在已知信息充足，只需確認(rèn)細(xì)節(jié)時(shí)使用。節(jié)省時(shí)間、提高效率封閉式提問時(shí)機(jī)把握123在患者回答后，重復(fù)或解釋以確保雙方理解一致。確認(rèn)患者理解通過追問，引導(dǎo)患者表達(dá)出更深層次的感受和需求。挖掘深層信息當(dāng)發(fā)現(xiàn)患者回答中存在矛盾或模糊之處時(shí)，及時(shí)澄清。澄清模糊或矛盾信息追問和澄清策略運(yùn)用在問診過程中，不斷提煉和總結(jié)患者的關(guān)鍵信息。提煉關(guān)鍵信息將患者的問題和需求進(jìn)行梳理，形成清晰的診療思路。梳理問題與需求在歸納總結(jié)后，向患者反饋并確認(rèn)理解無誤，以確保信息準(zhǔn)確傳遞。反饋與確認(rèn)歸納總結(jié)能力培養(yǎng)REPORTCATALOGDATEANALYSISSUMMARYRESUME04常見癥狀詢問要點(diǎn)及注意事項(xiàng)發(fā)熱詢問發(fā)熱起始時(shí)間、熱度、持續(xù)時(shí)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(shí)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(diǎn)指導(dǎo)患者使用疼痛量表（如數(shù)字評(píng)分法、視覺模擬評(píng)分法），描述疼痛部位、性質(zhì)（鈍痛、銳痛、絞痛等）、程度、持續(xù)時(shí)間及影響因素。疼痛描述介紹疼痛評(píng)估工具（如疼痛日記、疼痛評(píng)分卡等），闡述疼痛對(duì)患者生活質(zhì)量的影響及疼痛控制的重要性。評(píng)估標(biāo)準(zhǔn)疼痛描述方法及評(píng)估標(biāo)準(zhǔn)介紹注意事項(xiàng)和誤區(qū)提示注意事項(xiàng)強(qiáng)調(diào)問診過程中的溝通技巧（如傾聽、引導(dǎo)、確認(rèn)等），提醒患者提供準(zhǔn)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(shí)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(shí)，確保診斷的準(zhǔn)確性。REPORTCATALOGDATEANALYSISSUMMARYRESUME05溝通技巧在問診中應(yīng)用傾聽技巧設(shè)身處地地理解患者感受，用溫暖的語言回應(yīng)。同理心表達(dá)鼓勵(lì)患者表達(dá)用開放式問題引導(dǎo)患者詳細(xì)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(guān)注。傾聽、同理心表達(dá)技巧反饋技巧重復(fù)或總結(jié)患者所述，以確保理解正確。確認(rèn)信息準(zhǔn)確性用封閉式問題核實(shí)關(guān)鍵信息，如癥狀持續(xù)時(shí)間、程度等。澄清模糊信息當(dāng)信息不明確時(shí)，要求患者進(jìn)一步解釋或提供更多細(xì)節(jié)。反饋、確認(rèn)信息準(zhǔn)確性方法03保持一致性