2.interviewing the patient taking a history and doc
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Interviewing the Patient, Taking a Interviewing the Patient, Taking a History, and DocumentationHistory, and Documentation
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Learning Outcomes36.1 Name the skills necessary to conduct a
patient interview.
36.2 Explain the procedure for conducting a patient interview.
36.3 Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
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Learning Outcomes (cont.)
36.4 State the six Cs for writing an accurate patient history.
36.5 Document on the patient’s chart accurately.
36.6 Obtain a patient history.
36.7 Identify parts of the health history form.
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Introduction 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 with the patient can make a major difference in the patient’s attitude.
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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
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The Patient Interview and History (cont.)
Initial interview Communication tool More than just
completing a form Information
General health and lifestyle
Changes in health since last visit
Medical and health history Basis for all treatment
rendered Information for
Research Reportable diseases Insurance claims
The chart is a legal record of treatment provided. All information must be documented precisely and accurately!
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The Patient Interview and History (cont.)
Patient rights Information is subject
to legal and ethical considerations
AHA’s Patient’s Bill of Rights
Some patient rights Considerate and
respectful care Know the identity of
caregivers Refuse treatment Know the costs of care Confidentiality Have an advance
directive
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The Patient Interview and History (cont.)
Patient responsibilities Provide accurate information about past
medical conditions Participate in health-care decisions Provide a copy of their advance directive Follow physician’s orders for treatment;
inform physician if the patient anticipates problems with orders
Provide necessary information for insurance claims
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The Patient Interview and History (cont.)
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
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The Patient Interview and History: Interviewing Skills
Practice effective listening Active listener – hear, think about, and respond
Be aware of nonverbal clues and body language
Have a broad knowledge base Necessary to ask appropriate questions
Summarize to form a general picture Verify information
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The Patient Interview and History (cont.)
Eight steps to a successful interview1. Do research before the interview
Review patient records Be sure test and lab results are on the chart
2. Plan the interview Be organized before starting the interview Follow office policy
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The Patient Interview and History (cont.)
3. Make the patient feel at ease Icebreakers Appear relaxed Eye contact
4. Ask the patient for an interview Makes the patient feel more comfortable Emphasizes the importance of the process
8 Steps (cont.)
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The Patient Interview and History (cont.)
5. Ensure privacy / no interruptions Close door Do not use “pet” names
6. Be respectful with sensitive topics Watch for nonverbal cues Watch your own nonverbal cues
8 Steps (cont.)
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The Patient Interview and History (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.)
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The Patient Interview and History (cont.)
Methods of Collecting Patient DataEffective CharacteristicAsking open-ended questions
Requires more than a yes-or-no answer; results in more relevant data
Asking hypothetical questions
Enables the determination of the patient’s knowledge and whether it is accurate
Mirroring / verbalizing the implied
Restating what the patient said in your own words; stating what you believe the patient is saying
Focusing on the patient Shows the patient you are really listening to what he is saying; maintain eye contact; be relaxed and open
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The Patient Interview and History (cont.)
Methods of Collecting Patient DataEffective CharacteristicEncouraging the patient to take the lead
Motivates the patient to discuss or describe the issue in his own way
Encouraging the patient to provide additional information
Conveys sincere interest by continuing to explore topics in more detail when appropriate
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
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The Patient Interview and History (cont.)
Methods of Collecting Patient DataIneffective CharacteristicAsking 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
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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
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Apply Your Knowledge
ANSWER: An open-ended question which will allow the patient to explain the situation more clearly.
1. What type of question is the following: “How have 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 his or her own words. For example, the medical assistant might say, “You are finding it difficult to stay on a diet.”
Correct!
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Your Role as an Observer Nonverbal communication
May reveal more than patient’s words
Listen attentively and observe the patient closely Detect a problem that might
otherwise go unnoted
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Your Role as an Observer: Anxiety Common emotional
response White coat syndrome
Mild anxiety Heightened ability to
observe and make connections
Severe anxiety Difficulty focusing on
details Feels panicky and
helpless Lack of focus
Hinders your ability to get the information and cooperation needed
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Your Role as an Observer: Depression
Common symptoms Profound sadness Fatigue Difficulty falling asleep
or getting up in the morning
Loss of appetite Loss of energy
Occurs in late adolescence, middle age, and after retirement
Signs of substance abuse can be mistaken for depression
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Your Role as an Observer: Abuse Physical, emotional, or
psychological
Suspect abuse If the patient speaks in a
guarded way
Unlikely explanation for an injury
No history of the injury or history may be suspicious
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Your Role as an Observer: 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
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Your Role as an Observer: Abuse
Battered women Afraid to discuss
injuries Bring suspicions to
physician’s attention Encourage patient to
seek help Provide information on
community resources
Abused children Types
Physical Emotional Sexual Neglected
Must be reported to authorities
Community resources
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Your Role as an Observer: Abuse (cont.) Elder abuse
Disabilities that make an elderly person dependent can also leave him defenseless against abuse
Suspicious injuries or signs of neglect
Report to authorities
Find out if there is an elder abuse hotline in your area
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Your Role as an Observer:Drug and Alcohol Abuse
Serious social problems Decline in quality of
work or relationships Erratic behavior Mood changes Appetite loss Tiredness Blackouts Tremors
Substance abuse Use of a substance in an
unapproved medical manner
Not necessarily an addiction
Addiction Physical or
psychological dependence on a substance
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Documenting Patient Information: Six Cs
1. Client words
2. Clarity
3. Completeness
4. Conciseness
5. Chronological order
6. Confidential
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Documenting Patient Information (cont.) Contents of 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 Discharge summary and correspondences
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Documenting Patient Information (cont.)
Methods 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 education, follow-up
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Documenting Patient Information (cont.)
Common methods of maintaining records Conventional or SOMR – information arranged by
who provided it
POMR Most common Components
Database – medical history, diagnostic and lab reports, exam reports
Problem list – problems dated and assigned a number
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Documenting Patient Information (cont.)
POMR Components (cont.) Diagnostic and treatment plan – tests completed and
physician’s plan documented Progress notes
Note on each recorded problem Entered chronologically
Computerized medical records Combination of SOMR and POMR Improved accessibility to patient records
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Documenting Patient Information (cont.)
Terminology and abbreviations Avoid incorrect use Refer to
Office / facility policy
JCAHO “Do Not Use List”
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Recording 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 Questioning technique – PQRST
Provoke Quality of pain Region where located Signs and symptoms Time of onset
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Recording the Patient’s Medical History (cont.) Progress notes
Used for established patients Guidelines
Reverse chronological order Entries initialed by author Types – prescription refills, follow-up visits, telephone
calls, appointment cancellations / no-shows, referrals, and consultations
Patient identification information Date
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Recording the Patient’s Medical History (cont.)
Polypharmacy Document current
medications Prescription OTC Herbal
Encourage patient to maintaina current list
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Health history form Personal data Chief complaint (CC)
Reason patient made the appointment
Short and specific History of present illness
Detailed information about CC
Recording the Patient’s Medical History (cont.)
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Health history form Past medical history
All health problems Medication and allergies
Family history May help determine cause of current medical problem Ages, medical conditions Age at death and cause
Recording the Patient’s Medical History (cont.)
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Health history form Social and occupational history
Marital status Occupation Sexual orientation Alcohol / drug use
Review of systems – completed by practitioner
Recording the Patient’s Medical History (cont.)
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Wisdom is to the soul what health
is to the body.
~ de Saint-Réal