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KOMUNIKASI INTERPERSONAL DAN HUBUNGAN PASIEN DAN DOKTER DI KONTEKS ASIA TENGGARA
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Apa yang akan kita pelajari? • Temuan hasil penelitian • Komunikasi dasar • Komunikasi dokter pasien • Komunikasi terapetik • Tahapan komunikasi dokter pasien (sebagai lampiran)
Oleh: Yayi Suryo Prabandari FK UGM 2012
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Kajian • In-depth interview : • Communication teacher • As triangulation of prior research
TEMUAN HASIL PENELITIAN
• Panel expert • For validating the result
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Kajian sebelumnya: Masalah dalam komunikasi dokter pasien • Konflik gaya konsultasi: • Partnership vs paternalistik • Paternalistik di Asia dikarenakan: • Kurang waktu beban kerja dokter yang berlebihan • Pasien kurang memahami ttg kesehatan pendidikan rendah • Dokter Asia kurang terlatih dalam komunikasi • Pasien Asia sebetulnya juga kurang menyukai paternalistik • Harapan pasien: • Lebih dekat dan meningkatkan hubungan bermakna dengan dokternya • Lebih dekat berhubungan dengan keluarga • Memahami obat tradisional • Dokter sebaiknya respon terhadap komunikasi non-verbal • Dokter di Asia kurang menyadari bahwa pasien mengharapkan
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Result • Social and cultural context of their communities is very
important for Southeast Asian patients compared with patients from the west more autonomy • Much of the communication expressed by patients and their families with doctors is non-verbal, compared with western patients • Traditional medicine still holds an important place
hubungan yang lebih kuat dengan dokternya • Adanya konflik pengobatan modern dan tradisional • Gaya komunikasi dokter pasien diharapkan lebih ke partisipatori
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What should we educate and teach? • Comprehend the context • Enhance the responsiveness to Southeast Asian patients
KOMUNIKASI DASAR
• Build partnership communication during doctor-patient
consultation • Engage family and social support • Comprehend the meaning of traditional medicine among patients • Mastered in non-verbal communication
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Komunikasi efektif bila • Pesan yang dikirim oleh pengirim
disampaikan secara lengkap seperti harapan pengirim dan diterima oleh penerima selengkap yang diinginkan pengirim, serta pengirim mendapatkan umpan balik dari si penerima bahwa pesannya telah tersampaikan lengkap
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Tujuan Komunikasi • Memberikan informasi • Mempengaruhi orang • Mengekspresikan perasaan • Memobilisasi
• Agar pesan dapat tersampaikan
dengan lengkap, harus ada dialog
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Komunikasi dalam dunia kesehatan • Pengiriman pesan antara
pengirim dan penerima dengan interaksi di antara ke duanya yang bertujuan:
Dasar-dasar Komunikasi Mendengarkan
Bertanya
• menumbuhkan kepercayaan • menyebabkan kenyamanan • menimbulkan kepuasan
• meningkatkan kepatuhan (thdp
Penguasaan bahasa non verbal
pengobatan, berhenti merokok, diet, dsb) • menuju kesembuhan 7/24/2012
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Mendengarkan? Menghargai dan mendorong lawan bicara agar melanjutkan pembicaraannya
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Mendapatkan informasi dari lawan bicara, orang lain atau diri sendiri dengan mempertahankan diri untuk empati dan tidak menghakimi
Keterampilan untuk Mendengarkan Aktif Bertanya dengan pertanyaan terbuka
•Pertanyaan yang tidak bisa dijawab hanya dengan ya atau tidak •“Tolong ceritakan kapan Didik mulai merasa matanya mulai kabur”
Pertanyaan untuk mengklarifikasikan Memberikan respon yang singkat dan tetap memberikan input terhadap respon lawan bicara, serta menempatkan ide lawan bicara lebih dahulu
•Merespon lawan bicara agar memberikan informasi lebih •“Tadi Rudy mengatakan kalau pernah berusaha mengobati sendiri sebulan yang lalu, apakah bisa cerita lebih lanjut?”
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Keterampilan untuk Mendengarkan Aktif
Tips mendengarkan dengan baik
Melakukan refleksi
• Meringkas hal-hal yang dikatakan lawan bicara. • Lawan bicara mengatakan bahwa di rumahnya bapak, kakek, paman, kakaknya merokok, refleksinya adalah “Wah kelihatannya hampir seluruh keluarga merokok”
Reframing/menyusun kembali
• Mulai dengan pandangan positif • Lawan bicara mengatakan “Saya baru mengurangi jam kerja buk, belum bisa minta cuti ke kantor”, reframingnya: “sangat bagus jika Asti bisa mengurangi, beberapa pasien bahkan gagal untuk mengurangi jam kerjanya”
• • • • • • • • • • •
Konsentrasi Kontak mata Minat dan sikap tubuh Dorong lawan bicara Tanyakan kejelasan Bertanya secara detail Ringkas saat ini dan nanti Tinggalkan asosiasi & opini Jaga emosi Jangan terburu-buru Jeda bila diperlukan
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Penghargaan
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Penerimaan
• Terbuka “Bisa diceritakan sejak kapan Andi sering gemetar?”
• Tertutup Bas sudah makan sayur hari ini ya?
Toleransi
Jenis pertanyaan Prinsip mendengar
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• Cara berbicara • Penampilan • Postur tubuh • Gerakan tubuh • Ekspresi wajah
Aspek non-verbal
KOMUNIKASI DOKTER PASIEN
• Kedekatan
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Three function of doctor patient communication
Three function of doctor patient communication
• Building relationship
• Building relationship • Mastery on non verbal skills • Empathy • Personal support • Respect
• Assessing the patient’s problems • Managing the patient’s problems
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Mengembangkan empati: tahapan empati • Menghindari perspektif pasien • sengaja menghindari pertanyaan/pernyataan pasien • Secara artificial mengenali perspektif pasien • Menjawab “oh”, tanpa memberikan respon • Mengenali perspektif pasien secara implisit • Sedikit merespon • Mengakui/menghargai perspektif pasien • Parafrase dan mendorong pasien bercerita lebih lanjut • Mengkonfirmasi • Parafrase dan menguatkan perasaan pasien • Berbagi perasaan atau pengalaman • Menunjukkan memahami pasien dan memberikan penjelasan tentang pengalaman pasien lain
Partnership • Patients are more satisfied with physicians and
are more likely adhere to treatment recommendation when they feel a sense of partnership with their physician • Example of statement:
• “Let’s work together in developing a treatment plan
once I have reviewed some of the options with you”
• “After we’ve talked some more about your problems,
perhaps together we can work out some solutions that may help”
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Personal support
Respect • The physician’s respect for patients and their problems is
• Statement of personal support can enhance
rapport
• The physician should make explicit efforts to let the
patient know that he or she is there, personally • Example of statement: • “I want to help in any way I can” • “Let me know what I can do to help”
implied by attentive listening, nonverbal signals, eye contact and genuine concern • Respectful comments also help build rapport, improve the relationship, and help the patient cope with difficult situation • Example of statement: • “I’m impressed by how well you’re coping” • “You’re doing a good job handling the uncertainty • “Despite your feeling so bad, you’re still able to carry on at home and at work. This is quite an accomplishment”
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Three function of doctor patient communication
Structure of Doctor Patient Interview
• Assessing the patient’s problems • Non verbal listening behavior • Questioning style • Facilitation • Clarification and direction • Checking • Surveying problems • Avoiding leading (biased) questions
• Opening • Chief complaint and survey of problems • History of present illness (problem exploration) • Medical history • Family history • Patient profile and social history • Review of systems • Mental status
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Melakukan eksplorasi terhadap perspektif pasien
Perspektif
• Pikiran pasien tentang sebab dan perjalanan masalah
kesehatannya • Perasaan pasien, terutama “ketakutan/kekuatiran” tentang masalahnya • Harapan pasien tentang pelayanan kesehatan dan dokternya • Efek masalah kesehatannya tersebut terhadap kehidupan sehari-hari pasien • Pengalaman pasien atau saudaranya yang serupa • Respon terapetik yang pernah dicoba pasien
Disease/Penyakit:
Illness/Sakit:
• Deskripsi profesional
• Menunjuk pengalaman rasa
sebuah penyakit • Perspektif biomedis • Fokus pada kontrol dan pengobatan
sakit/distress • Menggambarkan efek pada yg
menderita dan bagaimana hal tersebut mempengaruhi yg lain • Fokus pada: Apa yg penyebabnya & siapa yang terpengaruh Apa yang dilakukan setelah itu Apa yang terjadi pada saat Anda menderita karena sakit
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Komunikasi Terapetik? • Terapetik : Berkaitan dengan terapi usaha untuk memulihkan sehatan seseorang yang sedang sakit; perawatan penyakit; pengobatan penyakit
KOMUNIKASI TERAPETIK
• Komunikasi terapetik: Pengiriman pesan antara pengirim dan penerima dengan interaksi di antara ke duanya yang bertujuan usaha untuk memulihkan sehatan seseorang yang sedang sakit
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Komunikasi Terapetik? Definisi yang lain……
Komunikasi Terapetik? Definisi yang lain……
• Saling memberi dan menerima antara pasien dan petugas
• Teknik verbal dan non verbal yang digunakan petugas
kesehatan di dalam: • Dukungan
• Informasi dan mengkoreksi distorsi • Umpan balik
• Harapan
kesehatan untuk memfokuskan pada kebutuhan pasien/klien • Pasien: seseorang yang sedang menderita • Klien: seseorang yang membutuhkan jasa
• Arti ekspresi pasien • Arti didengarkan dan dimengerti
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Tujuan Komunikasi Terapetik
Komponen Esensial Komunikasi Terapetik
• Menegakkan hubungan terapetik antara petugas
• Kerahasiaan
kesehatan dan pasien/klien • Identifikasi kebutuhan pasien/klien yang penting (client centered goal) • Menilai persepsi pasien/klien terhadap masalahnya
• Pembukaan diri (self-disclosure) • Privacy • Sentuhan
• Mendengarkan aktif • Melakukan pengamatan
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Teknik di dalam komunikasi • Terapetik: • Pertanyaan terbuka • Penerimaan • Pembukaan diri yang luas • Fokus • Melakukan pengamatan • Mendorong penggambaran persepsi • Mempresentasikan realitas • Mengawali kembali • Mengatakan keraguan • Tenang • Humor
• Non Terapetik: • Menasehati • Menyetujui • Mempertahankan • Memperkenalkan topik yang tidak relevan • Menghakimi • Respon “ya” dan “tidak” • Respon “harfiah” (bukan parafrase)
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Teknik di dalam komunikasi …………tambahan • Terapetik: • Refleksi • Menghargai perasaan pasien/klien • Memberikan informasi • Klarifikasi • Memverbalkan pikiran dan perasaan • Melakukan eksplorasi
• Non Terapetik: • Meyakinkan pasien/klien • Mempertanyakan • Mengekspresikan ketidaksetujuan • Memperkecil perasaan pasien/klien • Mengajukan komentar stereotip “Bagaimana perasaan Anda?” • Menantang
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TERIMA KASIH ATAS PERHATIANNYA
FUNGSI DAN TAHAPAN KOMUNIKASI DOKTER PASIEN
LAMPIRAN
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Doctor-Patient Communication • Doctor-Patient Communication “The spoken language is the most important tool in medicine.” • Eric Cassell
Beberapa slide (11-20) diambilkan dari Kristin Brodhun (January 31, 2003)
What is it?
• The cornerstone of good medical
practice • One of three central elements of the doctor-patient relationship Communication Continuity
of care Quality of care
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What is it?
Doctor-Patient Communication
• Medical interview is different from normal conversation
• Establishing rapport
• Talk is understanding, listening, and interpreting
• Discovering reason for visit
• Active listening is not focused just on symptoms, but their
• Verbally and physically examining patient
Doctor-Patient Communication
meaning to the patient
What is it?
• Discussing the condition • Establishing a treatment plan • Terminating the exchange
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Doctor-Patient Communication
Why is it important?
• Questioning patients most common and best method of
information gathering • 60-80% of medical diagnoses based on interview • Improves understanding of symptoms and concerns • Enhances reception of information and instructions by
patient, thus increasing compliance
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Doctor-Patient Why Communication Research shows…
is it important?
• Communication skills training results in more relevant
information in interview and better diagnoses • Longer visits make patients feel understood, relieved,
and enriched • More time with patients results in higher patient
satisfaction • Less satisfied patients participate in fewer health
enhancing tests and procedures and mammograms)
(like immunizations
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Doctor-Patient Why is it important? Communication Increased time with patients…
Doctor-Patient Communication
results in better care • •
saves money spent on unnecessary interventions
• • • •
prevents avoidable misdiagnoses, mistreatments, and patient misunderstanding
Doctor Overestimated compliance Belief that talk is unimportant “chatter” Dependent language Talking to vs. with patients Yes or no questions Patient questions dispreferred
What are some common mistakes?
Patient Unclear role definition Uninformed and unprepared Faulty information “Good” and “bad” patients Learned helplessness Self help attitude
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Doctor-Patient How can it be improved? Communication
Doctors can…
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Doctor-Patient How can it be improved? Patients can… Communication
• Get down on eye level with patients • Be genuinely interested-smile and add chitchat
• Trust patients as reliable narrators of symptoms
• Be sensitive to patients’ physical and emotional
state • Monitor use of jargon • Explain actions during physical exam • Involve patients in decision making
Learn how to communicate more effectively with doctor Be informed and prepared Present chief complaint first Come with a list of questions, and insist they be answered Take an active role in their health care Be assertive but not overly demanding Request clarification
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Three function of doctor patient communication • Assessing the patient’s problems • Questioning style
TAHAPAN KOMUNIKASI DOKTER PASIEN
• Open-ended questions • Example: • What problems brought you to the hospital? • Can you tell me some more about the headaches? • The open-to-closed cone • Example: • Physician: what can I do for you today? • Patient: I’ve been having terrible headaches • Physician: I’m sorry. Where is the pain • Patient: the pain is all over • Physician: is the pain sharp or dull? • Patient: dull
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Three function of doctor patient communication • Assessing the patient’s problems • Facilitation
Any comment or behavior on the doctor part that encourages the patient to keep talking in an open-ended manner can be considered facilitative. Repeating the last few words that the patient has said often invites the patient to keep talking Example: Physician: can you tell me some more about the headaches? Patient: well, they come on slowly over a period of days and seem to come on only in the hay fever season when my allergies get worse Physician: you say they only come in hay fever season? Patient: well, I guess I might get a headache in the winter or summer, but his is quite rare. Spring and fall tend to be the time the allergies and the headaches come
Three function of doctor patient communication • Assessing the patient’s problems • Clarification and direction • The objective of clarification and direction is to understand
clearly what patients mean to convey and to piece together a coherent narrative of patient’s problem. • Example: • Physician: you say the allergies have gotten out of hand. Can you help me understand what you mean when you talk about your allergies? • Patient: well, every spring and fall I sneeze a lot, and my eyes run and itch. My head feels congested and sometimes hurts
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Three function of doctor patient communication
Three function of doctor patient communication
• Assessing the patient’s problems • Checking
• Assessing the patient’s problems • Surveying problems
• Do check periodically • Language is replete with complex meanings that can be easily
misinterpreted • When in doubt, check • Example: • Physician: let me check to see if I understand what you have told me so far. You’ve been having spring and fall allergies all your life, but these have gotten much worse in the last two or three years since you’ve been under a lot more stress. You sometimes get headaches with these allergies. The headaches tend to come on slowly and develop over several days. You’re having one of these headaches now, and it’s getting so bad that you are having trouble at work and sleeping at night.
• “what else is bothering you” is the most important question • Surveying problems allows the patient and the physician to get
an understanding of the medical landscape and then decide which territory to explore first • In practice, it is recommended that the physician begin surveying problems shortly after eliciting and and briefly exploring the patient’s chief complaint • Example: • Physician: Now that I’ve heard a little about your headache, your allergies, and some of your recent stresses, I’d like to make sure I know something about all your other problems before we get back to them one at a time. What else is bothering you?
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Three function of doctor patient communication • Assessing the patient’s problems • Avoiding leading (biased) questions • Leading questions can result in significant and sometimes dangerous
misinformation, such as in the following example: • Physician: the pain doesn’t go down your arm, does it? • Patient: no, not really
Three function of doctor patient communication • Managing the patient’s problems • Education about illness • Negotiation and maintenance of a treatment plan • Motivation
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Three function of doctor patient communication • Managing the patient’s problems • Education about illness • Eliciting the patient’s ideas about etiology • Providing a basic diagnosis • Responding to the patient’s feelings about the diagnosis
Three function of doctor patient communication • Managing the patient’s problems • Negotiation and maintenance of a treatment plan • Checking baseline information • Describing treatment goals (with options, if any) and treatment
plans (with options, if any) • Checking understanding
• Checking the patient’s knowledge of the illness
• Eliciting patient preferences and commitments
• Providing details of the diagnosis
• Negotiating a plan cooperatively
• Checking the patient’s understanding of the problem
• Eliciting specific patient affirmation of intent • Planning for maintenance and relapse prevention
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Structure of Doctor Patient Interview • Opening • Chief complaint and survey of problems • History of present illness (problem exploration) • Medical history
Structure of Doctor Patient Interview • Opening • Introduction • Establishing goals of the interview • Obtaining patient consent to your interview plan • Establishing initial rapport • Establishing patient comfort
• Family history • Patient profile and social history • Review of systems • Mental status
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Structure of Doctor Patient Interview • Opening • Steps for an effective opening • Introduction: Hello, I am Rudy, a specialist candidate, Dr. Tri
gave me your name • Establish goal: Dr. Tri suggested that I talk with you about your
illness to help me learn how to know patients • Obtain patient consent: it is OK with you? • Establish initial rapport: you seem to be in pain • Establish patient comfort: how are you feeling right now?
Structure of Doctor Patient Interview • Chief complaint and survey of problems • Eliciting the chief complaint • Responding to emotions • Initial facilitation • Checking • Survey of problems • Problems to completeness • Negotiating priorities • Patient expectation • Patient ideas about the meaning of illness
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Melakukan eksplorasi terhadap perspektif pasien
Perspektif
• Pikiran pasien tentang sebab dan perjalanan masalah
kesehatannya • Perasaan pasien, terutama “ketakutan/kekuatiran” tentang masalahnya • Harapan pasien tentang pelayanan kesehatan dan dokternya • Efek masalah kesehatannya tersebut terhadap kehidupan sehari-hari pasien • Pengalaman pasien atau saudaranya yang serupa • Respon terapetik yang pernah dicoba pasien
Disease/Penyakit:
Illness/Sakit:
• Deskripsi profesional
• Menunjuk pengalaman rasa
sebuah penyakit • Perspektif biomedis • Fokus pada kontrol dan pengobatan
sakit/distress • Menggambarkan efek pada yg
menderita dan bagaimana hal tersebut mempengaruhi yg lain • Fokus pada: Apa yg penyebabnya & siapa yang terpengaruh Apa yang dilakukan setelah itu Apa yang terjadi pada saat Anda menderita karena sakit
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Structure of Doctor Patient Interview
Structure of Doctor Patient Interview
• History of present illness (problem exploration) • Narrative thread • Seven content items
• Medical history • Hospitalizations • Surgeries • Illnesses • Injuries • Medications • Allergies • Pregnancies • Exposures • Health maintenance • Psychiatric problems (utk mata ???)
• • • • • • •
• • • •
Location Quality Severity Timing Context Modifying factors Associated signs and symptoms
Completing the narrative thread Completing this process for every problems Responding to emotions throughout Evaluating the impact of illness on the patient’s quality of life
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Structure of Doctor Patient Interview
Structure of Doctor Patient Interview
• Family history • The doctor needs to inquire in detail about health problems and treatment of all firs-degree relatives
• Patient profile and social history • Patient profile
• Parents • Siblings • Children
• When looking for general health problems that might
“run” in a large family
• The doctor can use more open-ended global questions • Example: are there any other illnesses that run in your family, in you cousins or aunts and uncles?
• Interpersonal relationships: married, single, divorced, children,
extended family and friends, as well as sexual (activity, orientation, the use of protection) • Leisure activities: work, daily activities, leisure and organized groups • Other factors
• Social history • High-risk health behaviors • High-risk life situation (high stress and low support)
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Structure of Doctor Patient Interview • Review of systems (untuk mata: tergantung) • The organ systems that must be evaluated are: • • • • • • • • • • • • •
Skin Eyes Ears, nose, mouth, sinuses and throat Pulmonary Cardiovascular Digestive Genitourinary Hematologic Immune Endocrine Musculoskeletal Neurologic Psychiatric
Structure of Doctor Patient Interview • Mental status • Why every medical workup should include a mental status evaluation? • Doctor needs to be aware of abnormalities in mental functioning
• Poor memory or other cognitive problems can lead to unreliability
in the data collection process
• Brief mental status examination • General appearance and behavior • Speech • Mood and affect • Thought content • Cognition and sensorium
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Terima Kasih atas Perhatian Anda
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