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The clinical interview and history is a critical component of the evaluation and data collection process. The value of the interview goes well beyond the basic information collected through the questions presented in the interview format.

Preparing for the Interview Process

The format of the clinical interview and history includes multiple sections. A generic set of questions makes up the core information that crosses all disability groups. The forms for the patient’s present treatment, supplies, equipment, and family history accompany this set of questions. It is preferable to have at least one family member present during the clinical interview and history process. The presence of a family member gives the rehabilitation professional an opportunity to gain insight into family dynamics, an additional perspective on the disability from someone close to the patient, and valuable insight into psycho-social aspects of disability that cannot be obtained from just interviewing the patient. With a brain injury patient, it is critical to have a family member present who knew the patient pre-morbidly. If a family member is not available, include a close friend who knew the patient prior to the onset of the disability. It is only in this fashion that one can gain effective insights into pre- versus post-injury levels of function in higher-level executive function; psychological, emotional, and behavioral function; and motoric function areas.

Review the Records and Pre-Evaluation Material

Prior to conducting the interview, review and summarize the medical, health-related, professional, rehabilitation, educational, and employment records the patient has assembled. In addition, consider sending a pre-evaluation homework assignment to the patient and/or family consisting of the present treatment section, the supply section, and the equipment section of the interview sheets. This option enables him or her to assemble all the necessary information in advance of the interview. Many people will gather the information and properly complete the forms before the interview. Although it may still be necessary to review these with the patient and family to develop further information and ensure you have a full understanding of the situation, this method saves a great deal of time. Even when forms have not been fully completed, the information will already be organized, giving everyone a head start on accomplishing the job.

Members of the Patient’s Treatment Team

In the present treatment section, make sure patients assemble all their current physicians’ names, specialties, phone numbers, addresses, date of last visit, frequency of visits, and purpose of last visit. If they know the cost of an office visit, they should note this as well. Gather the same information for counselors, therapists, and anyone they might be seeing for alternative medical intervention such as acupuncture.

Prescription Medications

With respect to medications, it is important to obtain the basic information such as dosage, prescribed frequency of administration, purpose for which the medication is being given, and the name of the physician prescribing the medication. During the interview, be sure to ask how the medication is being taken, regardless of whether they have noted the frequency of administration or not. Also ask what they understand the purpose of the prescription to be. Patients and family members can sometimes have rather unusual understandings regarding diagnosis, basic physiology, and medication usage. Part of the clinical interview process is to ferret out patient perceptions and misconceptions.

Pre-Interview Telephone Conference

Next, conduct a pre-evaluation telephone interview with the patient and/or a family member closely involved with patient care to complete salient portions of the clinical interview and history. This telephone interview is particularly important when you are traveling out of the office to see the patient. If you are taking any materials, such as testing supplies, it can be extremely helpful to gather insights in advance of the interview. This will also shorten the evaluation process, reducing it to a tolerable duration for patients with more severely disabling conditions. In addition, it allows the clinician/rehabilitation professional to enter the evaluation process well informed and comfortable with the process.

The Orientation

Prior to engaging in the interview process, your first step is to initiate your role as an educator with the patient and family. Begin by introducing yourself, your background, and the purpose of your involvement in the case. If you are acting as a case manager, explain exactly what that role entails. If your intent is to complete a life care plan, define what that is and how one goes about building such a plan. Explain your role and the patient’s role in the process because such a plan cannot be built without the patient’s participation. If forensics is involved, it is particularly important to define your role and explain that you are not their advocate. Advocacy is the role of their attorney. You are there to educate all parties involved about disability and its impact on the life of the patient and the family. You are there to explain how disability impacts independent living, the ability of the patient to perform activities of daily living, and the ability to function in an educational setting or at work. You can discuss the impact of age and disability combining over time to create phase changes in the life care plan. It is your responsibility to use practice guidelines, research literature, reference texts, and your own knowledge base to build a foundation for the life care plan. It is important for the patient and family to appreciate your role, background, knowledge base, and ability since their active participation is necessary to help you complete your outlined responsibilities. The more confidence they have in you, the more help they will provide in supporting the job you have to complete.

The Ground Rules

You should begin the interview process by discussing a few basic ground rules with the patient and family members. Keep in mind that this portion of the interview is generic in nature and applies to all patients, regardless of disability. Therefore, use discretion in applying some of the comments, according to the nature of the disability. As one case in point, this reading includes a few concrete examples of applications to brain injury versus non-cognitive impairments.

Family Participation

Generally, you should conduct the clinical interview in the presence of both the patient and family, with few exceptions. At times it is reasonable to ask selective questions of a patient without a family member present, but it is rarely necessary to ask questions of the family with the patient removed. Simply conduct the orientation in an open, straightforward manner. Give the patient a sense of control, and treat each individual like an adult. Let patients know that if they feel tense, stressed, or agitated, they can request a break. At the same time, the interview is about them, and it is preferable to have them present.

As you ask each question, request that the patient try to answer the question first; only then should family members provide their perceptions or a corrected response. At no time should they answer for the patient or talk over the patient. If the family does so, resist the urge to immediately correct them because part of the objective of the evaluation is to observe family dynamics. Observing these interactions, even after hearing specific instructions regarding this process, can be extremely insightful. After a family member has continued to interrupt a patient two or three times, reiterate the fact that you need to hear a complete response from the patient first. If the pattern later begins to repeat itself, make note of the behavior and intervene once again.

Identifying, tracking, and carefully noting such patterns in family dynamics and interactions can help in the design of the family counseling and individual behavioral or counseling programs built into the life care plan. In this fashion, the plans become very workable in the real world instead of just a shell for show.

Pediatric Patients

Even in the case of the pediatric patient, try to conduct much of the interview with the parents while the child remains in the room. This approach allows you to observe the child for two or more hours before beginning to work with the child. Again, note family dynamics and interactions. You also may have the chance to observe tube feeding, child behavior patterns, seizure activity, or even the child in free play. Note the child’s independent ability to move or thrust his/her extremities, to crawl, to roll, or to walk. In addition, the interview provides an extended period of time for the child to get used to the life care planner’s voice. Take care to keep your voice calm, low-key, and non-threatening throughout the interview. Remember that part of your goal is to have the child view you as non-threatening and your visits painless, compared to the many prior doctor visits that child may have experienced.

Length of the Interview

It is important to plan sufficient time to get through the interview process. Depending on the complexity of the disability, you typically will need three to four hours if you are utilizing the format provided in this course, coupled with one of the disability-specific forms.

For many of the questions asked relative to the common disabilities you will evaluate, you will only be looking for a basic answer from the patient. With some patients, (the brain injured, the psychiatric/psychological patient, and others), you will find yourself looking beyond the basic response for insight.

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Demographic Information

The individual with a brain injury who cannot provide a social security number, telephone number, or address can be providing you a significant detail. At the same time, do not jump to conclusions. Check whether the patient and family moved recently, or even in the last six months. If they moved post-trauma, the patient’s memory lapse may be an indication of difficulty in learning and retaining new information. If it is a pre-morbid address, the patient’s inability to respond accurately may reflect much more significant damage. On the other hand, if the problem is psychiatric in nature, the issues, although significant, may reflect much different insights.

In each instance, no matter how long it may take, it is important to try and establish the patient’s response first. The patient’s memory of what is accurate, perception of what is going on, and understanding of what is wrong all represent important insights into the dynamics of the disability.

As you move through the questions, it is important to establish where the individual was born and where he or she received elementary and secondary education. This information can help provide some important insights into educational development, even within state educational systems.

Nature of the Injury

In asking how an individual was injured, it is important to steer away from issues of liability. You are not requesting a reconstruction of the accident. The issues within this section relate merely to the mechanics of the injury.

Did the individual lose consciousness? If so, for how long? Does he or she recall the accident? Is there any loss of memory for events prior to the accident, (retrograde amnesia)? If there was a loss of consciousness, did the patient awaken at the scene? Does he or she recall emergency workers at the scene or being treated at the scene? Does the patient recall transport to the hospital or treatment in the ER?

When were family members first notified of the accident? How long after the accident did they arrive at the hospital? How long was it before they saw the patient? Did the patient recognize family members? What were family members told by the doctor?

Rehabilitation Programs Since Onset

The next step is to move the patient through the initial hospitalization into all rehabilitation programming since the onset of the disability to the present. It is best to do this with your notes on the medical records by your side.

What does the patient remember of the acute care experience? What does he/she recall of the inpatient rehabilitation program? What therapies did he/she receive? Was the rehabilitation program a positive experience? What levels of function and independence did he/she achieve? On discharge, where did the patient go? What level of support care did he/she require? Who provided that care? Did the patient receive any outpatient rehabilitation programming? Can he/she recall what therapies were recommended and on what schedule? It is important to track this information through to the current schedule the patient is receiving, including his or her attitude about therapy.

Prior Medical History

A complete review of the patient’s prior medical history is important. Life care planning deals with the whole patient, not just the current disability. At times, depending on the basis for establishing the plan, we may have to distinguish between the preexisting medical history and the current disability, but we always deal with the whole person.

Did the patient have any history of accidents or injuries resulting in any hospitalizations, medical care or disability? Was there a prior history of chronic medical or health care conditions for which the patient was being treated such as asthma, heart disease, high blood pressure, pulmonary disorders, and the like? Had the patient ever been treated for any psychiatric or psychological conditions or been prescribed psychotropic medications? Establish whether the patient had any surgeries or had ever been hospitalized.

Chief Complaints and Current Disability

Approach chief complaints or current disability in three ways. First, ask the patient to describe his or her understanding of the diagnosis and to list the primary problems or complaints, as they currently exist. Do this without regard to what has occurred historically; base it on what is occurring now. It may help to request that the patient disregard the fact that you have read his or her medical records and to imagine he/she is introducing the problems to you for the first time.

Again, ask the family not to interrupt, and to note that they will be asked the same question after the patient responds. Tell the patient that when he or she is done, family members will be given the opportunity to give their perception. Perceptions may differ, and it may not be easy for the patient to listen to what others have to say. Although patient can leave if they wish, it is preferable that they not do so. Nevertheless, if they would like a break at any point, all they have to do is request one.

Second, after the patient and each family member has had the opportunity to provide insight into the disability from their perspective, turn to disability-specific questions. These questions are specifically designed to address areas of difficulty commonly expressed by those with a certain type of injury.

Third, it is important to document the disability from the patient and family perspective with great specificity. This detail should be included not only in your notes, but also be translated from your notes to your report.

Such documentation by the plaintiff’s life care planner or case manager is critical in a forensic setting. When you are given the task of considering the needs of a patient from the defense perspective, without the opportunity to personally evaluate the patients, these reports then become your eyes and ears, and you rely on such notes for critical insights.

Psychosocial Issues

Patient and family psychosocial issues are the next area of input. Although the rehabilitation professional may be tempted to provide only his or her own insights, this is not the purpose of this section. Ask the patient what insight he/she has into the psychological response to the onset of disability, then ask how the patient sees the disability having impacted his or her family. Subsequently, ask the family to give input. If the rehabilitation professional has comments to make from his or her own observations thus far in the interview, it is appropriate to make them as long as they are carefully distinguished from those of the patient or family members.

Physical Limitations

The questions in this section are straightforward as long as the professional remembers the following: Unlike some chronic low back patients with workers compensation claims, some patients with catastrophic disabilities will answer based on what they hope to be able to do in the future, rather than what they are currently able to do.

It is important to obtain a realistic understanding of the patient’s current physical limitations and abilities. This is another reason for trying to have at least one family member present during the interview. Explore each item carefully and, depending on how far post-injury the patient may be, consider having a follow-up interview. For example, if you are interviewing a spinal cord patient 8 to 10 months post-injury, then a follow-up interview at 14 to 18 months post-injury (and even longer post-injury, if possible) is certainly in order.

Environmental Influences/Activities of Daily Living (ADLs)/Social Activities/Personal Habits

Although all the questions are fairly straightforward, any question in the clinical interview can represent subtleties beyond the basics. Reviewing social activities with a patient can reveal social isolation, withdrawal, and signs of depression or anxiety disorder. In reviewing personal habits, it is appropriate to determine if anyone in the home is smoking or has an alcohol or drug problem. Smoking, even if the patient is a non-smoker, has significant implications for skin care in spinal cord injury, due to exposure to second-hand smoke. The interviewer must focus on more than concrete facts. Instead, develop a critical thinking framework and look beyond the obvious in your interview technique.

Employment History

Typically, an employment history is something you should ask the patient to do as a homework assignment prior to the interview. Once accomplished, you should review it with the patient during the interview. This history is an excellent source of pre-morbid data on patient levels of function. Work provides insight into a patient’s level of educational development, ability to work with people, task orientation, ability to focus and concentrate, physical capacities, mental capacities, and a wide range of other data. Jobs can be broken down through worker trait groups into very specific requirements, providing immense detail about an individual’s pre-morbid levels of ability and function. This history is much more than just a resume.

Observations

This is the interviewer’s opportunity to comment directly on what he/she has observed about the patient’s mental status in the evaluation. Orientation addresses whether the patient was alert and oriented to person, place and time (oriented times three).

Was the patient’s stream of thought clear and rational or confused, bizarre, disjointed, or tangential? Was the patient able to clearly communicate thoughts when asked direct questions?

Was the patient’s overall approach to the evaluation positive, negative, flat, or indifferent? Did the patient show an overall positive attitude and seem to have insight into his or her physical and psychological problems?

Comment on the patient’s overall appearance. Was the patient well cared for? Did the patient appear overtly disabled? Did the patient demonstrate a lot of chronic pain behaviors? Was the patient demonstrating a lot of chronic disability behaviors? Any relevant comments the interviewer wishes to make would be pertinent in this section.

Tests Administered

Unless you are conducting psychological or developmental tests, this section is irrelevant and should be skipped.

General Comments

The comment section is available for general comments or notes the interviewer wishes to make.