Medical assisting Administrative and clinical procedures (5e) Chapter 36 Patient interview and history

After completing chapter 36, you will be able to: Identify the skills necessary to conduct a patient interview; recognize the signs of anxiety; depression; and physical, mental, or substance abuse; use the six Cs for writing an accurate patient history; carry out a patient history using critical thinking skills;...

Patient Interview

and History

Learning Outcomes (cont.)

36.1 Identify the skills necessary to conduct a

patient interview

36.2 Recognize the signs of anxiety; depression;

and physical, mental, or substance abuse

36.3 Use the six Cs for writing an accurate patient

history

36.4 Carry out a patient history using critical

thinking skills

• The medical assistant

– Prepares the patient

and the patient’s chart

– Conducts a patient

interview

– Records the necessary medical history

How you conduct yourself during the first few moments with the patient can make a major

difference in the patient’s attitude.

The Patient Interview and History

The Patient Interview and History (cont.)

• Medical and health history

– Basis for all treatment rendered

• Information is subject to legal and ethical

considerations

• The Patient Care Partnership:

Understanding Expectations, Rights, and

Responsibilities

Privacy (cont.)

• Some patient rights

– Considerate and respectful care

– Know the identity of caregivers

Privacy (cont.)

• Some patient responsibilities:

– Provide accurate information

– Participate in healthcare decisions

– Provide a copy of their advance directive

– Follow physician’s orders

– Provide information for insurance claims

Privacy (cont.)

• HIPAA

– Enforcement began in 2003

– Individual health-care workers can be subject to fines up to $250,000 and

10 years in jail

Privacy (cont.)

• HIPAA requires

– No use or disclosure of protected information

for purposes not in the privacy notice– Written authorization to release information

– Posting the privacy notice

Communicating with Professionalism

Interviewing Skills

• Practice effective listening

• Be aware of nonverbal clues and body

language

• Have a broad knowledge base

• Summarize to form a general picture

Interviewing Skills (cont.)

• Have a broad knowledge base

• Summarize to form a general picture

– Consider the importance information obtained

– Repeat back a summary of the information

Interviewing Successfully

1 Do research before the interview

– Review medical record

– Note issues that may impact health

– Be sure appropriate reports are in the record

1 Plan interview – follow office policies

Interviewing Successfully (cont.)

3 Request the interview

3 Make the patient feel at ease

relaxed

Interviewing Successfully (cont.)

5 Ensure privacy/no interruptions

– Private area or close door

– Develop a rapport with the patient

5 Be respectful with sensitive topics

– Watch for nonverbal cues

– Watch your own nonverbal cues

Interviewing Successfully (cont.)

7 Do not diagnose or give an opinion

– Refer questions to physician

– Remember your scope of practice

8 Formulate a general picture

– Summarize key points

– Ask if patient has questions or needs to

add additional information

Interviewing Successfully (cont.)

Interviewing Successfully (cont.)

Conveys sincere interest by continuing

to explore topics in more detail when appropriate and provides clarification

patient’s knowledge and fears Uses

reflection to form a thought, idea, or opinion

Interviewing Successfully (cont.)

Interviewing Successfully (cont.)

Probing Once patient has finished, probing

may make him defensive Agreeing/disagreeing

with patient Implies that the patient is either “right” or “wrong”; block to

communication

Apply Your Knowledge

ANSWER: An open-ended question which will allow

the patient to explain the situation more clearly.

2 What type of question is the following: “How have you

been managing your diabetes?”

1 What are four skills you will need to conduct a

successful interview? ANSWER:

Effective listening

Being aware of nonverbal cues

Having a broad knowledge base

Summarizing to form a general picture

Your Role as an Observer

• Nonverbal communication

patient’s words

• Listen attentively and

observe the patient closely

• Common emotional

response

• Mild anxiety – heightened focus

• Severe anxiety – difficulty focusing

• Either a heightened focus or a lack of

focus can hinder the interview process

– Loss of energy

• In adolescence

substance abuse

– Notify physician if any of these are suspected

• Middle age – triggered by life events

• Elderly – mistaken for senility

Physical and Psychological Abuse

injury

Physical and Psychological Abuse (cont.)

• Signs of abuse

– Head injuries/skull fractures

– Burns that appear deliberate

– Broken bones

– Bruises – multiple; in various stages of

healing

Physical and Psychological Abuse (cont.)

• Other signs of abuse

– A child’s failure to thrive

– Severe dehydration or underweight

– Delayed medical attention

– Hair loss

– Drug use

– Genital injuries

The Interview and Abuse

• Women, children, and elderly

– More likely to be abused

– Observe carefully during interview

– Report suspected abuse to physician or

supervisor– Have a list of hotline numbers available

The Interview and Abuse (cont.)

• Women

– Often feel shame

– Listen carefully, be nonjudgmental

• Children

– Observe for nonverbal cues

– Watch relationship between child and caregiver

• Elderly – observe carefully

Drug and Alcohol Abuse

• Substance abuse and addiction

– Symptoms vary with substance abused

Apply Your Knowledge

While interviewing a female patient, you notice bruises on

her forearms and face You ask her how she got the

bruises, and she says she cannot remember, but she

must have fallen down What should you do?

ANSWER: The patient’s answer is vague and

evasive Since multiple bruises may be a sign of

abuse, you should tell the physician of your

suspicions

Documenting Patient Information

• C lient’s words – record exactly

• C larity – use medical

terminology and precise descriptions

• C ompleteness – fill in forms

Documenting Patient Information (cont.)

• C onciseness

• C hronological order – date all entries

• C onfidentiality – protects patient’s privacy

Contents of Patient Charts

Contents of Patient Charts

• Physician’s diagnosis and treatment plan

• Operative reports

• Informed consents

• Discharge summary

• Correspondence

Methods of Charting (cont.)

• Problem-oriented medical records (POMR)

– Database ~ foundation of the POMR record

– Problem list – each problem is dated and

numbered– Diagnostic and treatment plan

– Progress notes – chronological

order

Methods of Charting (cont.)

Methods of Charting (cont.)

• Computerized medical records

– Combination of SOMR and POMR

– Improved accessibility

to patient records

Apply Your Knowledge

Matching:

_ Precise descriptions

_ What the patient says

_ Charting based on problems

_ Contains options for treatments

_ Arrangement based on source

of information

_ Lists patient conditions

_ Essential to protect patient privacy

J O B

Recording the Patient’s Medical History

• Includes pertinent information

– About the patient and patient’s family medical

history– Age, surgical history, allergies, medications

– Must be complete

and accurate

• Key correct information into the EHR

• Pay attention to spelling

• Use only approved abbreviations

• Select the correct item from menus

Progress Notes

• Guidelines

– Arrange in reverse chronological order

– Initial / sign entries

– Patient identification information

– Date & time

• Document current medications

• Encourage patient to maintain a

current list of medications

Health History Form

• Personal data

• Chief complaint (CC)

– Reason patient made the appointment

– Short and specific

• History of present illness – detailed

information about CC

Health History Form (cont.)

• Past medical history

– All health problems

– Medications

– Allergies

• Family history

– May help determine cause of current problem

– Ages, medical conditions

– Age at death and cause

Health History Form (cont.)

• Social and occupational history

Apply Your Knowledge

When recording the patient’s chief complaint,

you will probably need to ask more questions What tool can you use to help you ask the appropriate questions?

ANSWER: The interviewing technique – PQRST, will

help you to remember the types of questions that are

appropriate for the problem.

In Summary

36.1 The skills necessary to conduct an interview

include effective listening, awareness of nonverbal cues, use of a broad knowledge base, and the ability to summarize a general picture

36.2 Anxiety can range from a heightened ability to

observe to a difficulty in being able to focus

Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and lost of appetite Abuse can be physical or psychological

In Summary (cont.)

36.3 The six Cs for writing an accurate patient

history include client’s words, clarity, completeness, conciseness, chronological order, and confidentiality

36.4 When obtaining a patient history, you can use

open-ended questions, active listening, clarification, restatement, reflection, and the PQRST interview technique; review the

information obtained, determine the importance, and then document the facts accurately

End of Chapter 36

Wisdom is to the soul what health is to the body

~ de Saint-Réal