Lecture Clinical procedures for medical assisting (4/e): Chapter 5 – Booth, Whicker, Wyman

Chapter 5 - Interviewing the patient, taking a history, and documentation. The objectives of this chapter are: Identify the skills necessary to conduct a patient interview; implement the procedure for conducting a patient interview; detect the signs of anxiety, depression, and physical, mental, or substance abuse. use the six Cs for writing an accurate patient history.

Interviewing the

Patient, Taking a

History, and

5.3 Detect the signs of anxiety; depression; and

physical, mental, or substance abuse.

5.4 Use the six Cs for writing an accurate patient

history

Learning Outcomes (cont.)

5.5 Write on the patient’s chart accurately.

5.6 Carry out a patient history.

5.7 Identify parts of the health history form

5.8 Use critical thinking skills during a patient

interview

• The medical assistant

prepares the patient

and the patient’s chart

before the physician

enters the exam room

to examine the patient

• Conducting the patient interview and recording the

necessary medical history are essential

to the practitioner’s examination process

How you conduct yourself during the first few moments

The Patient Interview and History

• Patient interview

– First step in

examination process– Establish a

relationship with the patient

• Chief complaint

– Subjective statement

by patient describing the most significant symptoms or signs of illness

The Patient Interview and History (cont.)

• Medical and health history

– Basis for all treatment rendered

– Refuse treatment– Know the costs of care– Confidentiality

– Have an advance directive

Patient Responsibilities

medical conditions

inform physician if the patient anticipates

problems with orders

insurance claims

Patient Privacy

• HIPAA

– Provide patient with written notice of practices

regarding use and disclosure of health information

– Facilities may not use or disclose protected

information for any purpose not in the privacy notice

– Written authorization is required to release

information – Privacy notice must be posted

Patient 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.

Interviewing Skills

• Practice effective listening

– Be an active listener

– Hear, think about, and respond

• Be aware of nonverbal clues and body language

• Have a broad knowledge base so you can to ask

appropriate questions

• Summarize to form a general picture – verifies

information

The Patient Interview (cont.)

Eight steps to a successful interview

1 Do research before the interview

– Review patient records

– Be sure test and lab results are on the chart

1 Plan the interview

– Be organized before starting the interview

– Follow office policy

The Patient Interview (cont.)

3 Make the patient feel at ease

– Makes the patient feel more comfortable

– Emphasizes the importance of the process

The Patient Interview (cont.)

5 Ensure privacy/no interruptions

– Close door

– Do not use “pet” names

5 Be respectful with sensitive topics

– Watch for nonverbal cues

– Watch your own nonverbal cues

The Patient Interview (cont.)

7 Do not diagnose or give an opinion

– Refer questions to physician

– Do not go beyond your scope of

practice

8 Formulate a general picture

– Summarize key points

– Ask if patient has questions or needs to

add additional information

8 Steps (cont.)

Methods for Collecting Patient Data

questions Enables the determination of the patient’s knowledge and whether it is accurate

Mirroring/verbalizing the

implied Restatementwords; stating what you believe the patient is of what the patient said in your own

saying Focusing on the patient Shows the patient you are really listening to what

he is saying; maintain eye contact; be relaxed and open

Methods for Collecting Patient Data (cont.)

Encouraging the patient to

take the lead

Motivates the patient to discuss or describe the issue in his own way

Encouraging the patient to

evaluate situation Provides an idea of the patient’s point of view; allows for determination of patient’s knowledge

and fears Uses reflection to form a thought, idea,

or opinion

Methods for Collecting Patient Data (cont.)

Asking closed-ended

questions Provides little information; allows no explanation of answers; require yes-or-no answers

Asking leading questions Suggests a desired response; patient tends to

agree without elaboration

Challenging the patient Patient may feel you are disagreeing with him; he

may become defensive; blocks communication

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

Using Critical Thinking Skills

• Getting at an underlying meaning

– Encourage verbalization

of concerns– Mirror response– Restate patient’s comments

– Verbalize what you think the patient is implying

Apply Your Knowledge

ANSWER: An open-ended question which will allow the patient to explain

the situation more clearly.

you been managing your diabetes?”

2 How would you use mirroring if the patient made the

following statement during an interview? “I just cannot

seem to stay on a diet no matter how hard I try.”

ANSWER: The medical assistant should restate what the patient says in

Your Role as an Observer

• Nonverbal

communication may

reveal more than

patient’s words

• Listen attentively and

observe the patient

closely

– Feels panicky and helpless

– Lack of focus

• Hinders your ability to get the information and cooperation needed

– Loss of appetite

– Loss of energy

• Occurs in late adolescence, middle age, and after

retirement

• Signs of substance abuse can be

mistaken for depression

injury, or history may

Abuse (cont.)

• Signs of abuse

– Head injuries/skull

fractures– Burns that appear

deliberate– Broken bones

– Bruises – multiple in

various stages of healing

– Child’s failure to thrive– Severe dehydration/

underweight– Delayed medical attention

– Hair loss– Drug use– Genital injuries

Abuse (cont.)

• Women, children, and elderly

– Are more likely to be abused

– Observe carefully during interview

– Report suspected abuse to physician or

supervisor – Have a list of hotline numbers available

Drug and Alcohol Abuse

• Serious social

problems

– Decline in quality of

work or relationships– Erratic behavior

• Addiction

– Physical or psychological dependence on a substance

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

Six Cs of Documenting Patient Information

Patient Chart

• Registration form

• Patient medical history

• Test results

• Records from other physicians or hospitals

• Physician’s diagnosis and treatment plan

• Operative reports

• Informed consents

Method of Charting

• SOAP – documentation in a logical

manner

– Subjective data – what the patient says

– Objective data – measurable information

– Assessment – diagnosis or impression of

problem – Plan of action – options for treatment,

medications, tests, consults, patient

Methods for Maintaining Records

Methods for Maintaining Records (cont.)

• Problem-oriented medical records (POMR)

– Database – medical history, diagnostic and lab

reports, exam reports– Problem list – problems dated and assigned a number

– Diagnostic and treatment plan – tests completed and

physician’s plan documented– Progress notes

• Note on each recorded problem

• Entered chronologically

Methods for Maintaining Records (cont.)

• Computerized medical records

– Combination of SOMR and POMR – Improved

accessibility to patient records

Terminology and Abbreviations

• Avoid incorrect use

• Refer to

– Office/facility policy

– TJC “Do Not Use List”

Apply Your Knowledge

Matching:

_ Precise descriptions A Problem list

_ What the patient says B POMR

_ Charting based on problems C Clarity

_ Contains options for treatments D Confidentiality

_ Arrangement based on source of information E Subjective data

_ Lists patient conditions F Plan

_ Essential to protect patient privacy G Computerized records

_ Accessibility to records H SOMR

!

The Patient’s Medical History

• Includes pertinent information

– Patient and patient’s family

– Age, previous illness, surgical history,

allergies, medications history, and family medical history

– Must be complete

and accurate

The Patient’s Medical History (cont.)

• Determine chief complaint

Progress Notes

• Used for established patients

• Guidelines

– Reverse chronological order

– Entries initialed by author

– Types – prescription refills, follow-up visits,

telephone calls, appointment shows, referrals, and consultations

cancellations/no-– Patient identification information

– Date

• 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

– Medication and allergies

• Family history

– May help determine cause of current medical

problem – Ages, medical conditions

Health History Form (cont.)

• Social and occupational history

Apply Your Knowledge

In what part of the health history form do

you record information about whether a

patient smokes, drinks, or uses tobacco?

ANSWER: The social and occupational history portion

of the health history form.

In Summary

5.1 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

5.2 For a successful interview you must research, plan,

and ask permission Also put the patient at ease, interview in a private area, be sensitive, do not diagnose, and form a general picture

In Summary (cont.)

5.3 Anxiety can range from a heightened ability to

observe to a difficulty to focus Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and loss of appetite Abuse can be physical, such as an injury, or psychological, such as neglect

5.4 The six C’s for writing an accurate patient history

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

In Summary (cont.)

5.5 Accurate documentation requires attention to detail

The medical record is a legal document Correct spelling and correct abbreviations are mandatory

5.6 When obtaining a patient history you can use the

PQRST interview technique, review the information obtained, determine the importance, and then

document the facts accurately

In Summary (cont.)

5.7 The health history form includes personal data, chief

complaint, history of present illness, past medical history, family history, social and occupational history, and the review of systems

5.8 Critical thinking during the patient interview requires

the use of open-ended questions, active listening, clarification, restatement, and reflection

End of Chapter 5

Wis dom is  to  the s oul what  health is  to  the body.