Entrevista e anamnese: uma análise crítica dos vários autores e uma proposta de roteiro e de registro de consulta baseados no método clínico centrado no paciente

Abstract

It's a challenge to everyone involved in teaching clinical semiology: students, teachers, doctors and patients. Our objective is to analyze critically the texts most used in teaching the construction of clinical history and to propose a structure of the interview and the register most appropriate to the patient-centered clinical method (PCCM). There are important differences between the various authors that can cause difficulties for novices learners. In general, these texts are organized around the structure of the registry, to develop the construction of the clinical history. The interview, more fluid and interactive, has a logical structure. The steps of a clinical consultation using the PCCM are opening (getting ready, initial rapport, establishing the patient agenda and negotiating the agenda), exploration (biomedical or disease, patient or personal and contextual perspectives), physical examination, clinical reasoning, planning(management, which includes building a shared understanding of the problem and negotiating a plan) and closing (summarization and understanding check). In this text, we go through the structure and used nomenclature, trying to understand the intentionality, the presence of a criterion, as well as the coherence of its contents. Finally, we end with a proposal of structure for the clinical interview and its registry, that moves from the disease-centered clinical method to PCCM and that is feasible to the current clinical practice