Chapter 20Chapter 20

Patient InterviewPatient Interview

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Learning ObjectivesLearning Objectives

Define and spell key terms Define the purpose and the key

components of the patient interview List nine interviewing techniques and

list the purpose of each Identify effective strategies for

interviewing the talkative patient and the quiet patient

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Learning ObjectivesLearning Objectives Differentiate between closed questions,

open-ended questions, and directive statements and give an example of each

List five obstacles to effective interviewing and discuss an effective alternative strategy for each

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Learning ObjectivesLearning Objectives

Describe techniques that may be used to help patients feel more comfortable discussing sensitive information

List at least three examples of age-appropriate interviewing techniques

List the main components of the medical history

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Learning ObjectivesLearning Objectives

Conduct a patient interview to obtain a medical history

Accurately document the patient’s medical information on a history form

Describe three methods of documentation

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First ImpressionsFirst Impressions

Medical assistant’s role is to connect patient with physician or provider

Medical assistant checks vital signs Medical assistant interviews patient to

obtain medical history Use effective communication Summarize interview when finished

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Interviewing TechniquesInterviewing Techniques

Closed questions Open-ended

questions Directive

statements Restating

Reflecting Redirecting Active listening Silence Summarizing

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The Talkative PatientThe Talkative Patient

Establish clear guidelines for the interview Medical assistant may have to redirect

patient to specific interview questions Ask closed questions that require a “yes” or

“no” answer To ensure accuracy of information, restate

the information Redirect patient in kind, assertive manner

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The Quiet PatientThe Quiet Patient

Quiet or shy, provide little information Ask open-ended questions that require

more than one- or two-word answers Practice wording questions ahead of

time Use directive statements

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Obstacles to Effective InterviewingObstacles to Effective Interviewing Medical assistants should refrain from

offering medical advice Do not provide false reassurance Keep language and vocabulary

professional and accurate Speak in terms the patient can

understand, do not use medical jargon Take care not to imply judgment

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Discussing Sensitive TopicsDiscussing Sensitive Topics Personal information such as sexual activity,

use of birth control, number of sexual partners, bowel and bladder function, and menstrual pattern

Provide privacy and patient comfort; allow patient to remain clothed

Assure information will remain confidential Begin interview with general questions and

end with more personal questions

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Age-Appropriate CommunicationAge-Appropriate Communication

Adapt vocabulary and interviewing strategies appropriate to age of patient

Children—sit at eye level to make eye contact

Older children and adolescents—offer choices whenever possible

Elderly—adapt for any sensory or perceptual deficits

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The Medical HistoryThe Medical History

Logistical data—DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings

PMH—immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries

FH—information about parents, siblings, and children

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The Medical HistoryThe Medical History

SH—patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol

ROS—systematic collection of data regarding patient’s overall health

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DocumentationDocumentation Patient’s chart is a legal document Documentation should be thorough,

legible, and professional Do not document in pencil, do not use

unapproved abbreviations, do not add late entries, make corrections following facility’s policy guidelines, document facts, and do not make assumptions

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Types of DocumentationTypes of Documentation

Source-oriented medical record—SOMR Problem-oriented medical record—

POMR SOAP—subjective, objective,

assessment, plan SOAPE—subjective, objective,

assessment, plan, evaluation

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Subjective DataSubjective Data

Known only by the patient Patient must share information with the

health team Describe pain, nausea, emotional

distress Include patient’s own words; enclose in

quotation marks

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Objective DataObjective Data

Obtain through observations by health team

Record data accurately Use quantitative terms Include physical examination findings,

weight, vital signs, and test results

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AssessmentAssessment

Physician’s conclusion about the patient’s condition or diagnosis

Physician may list primary symptoms May rule out (R/O) certain conditions

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Plan of Care and EvaluationPlan of Care and Evaluation

Physician describes how patient’s problem will be further evaluated and treated

May include diagnostic studies or treatments

Evaluation describes the patient’s understanding of the overall plan as well as his or her compliance with it

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Discussion Discussion Differentiate the following subjective

and objective findings: Headache Ecchymosis Fever Diarrhea Vomiting at home Vomiting at clinic

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CreditsCredits