interviewing the patient, taking a history, and documentation

CHAPTER

© 2011 The McGraw-Hill Companies, Inc. All rights reserved.

36Interviewing the Patient, Taking a

History, and Documentation


36-2

Learning Outcomes

36.1 Identify the skills necessary to conduct a patient interview.

36.2 Implement the procedure for conducting a patient interview.

36.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse.

36.4 Use the six Cs for writing an accurate patient history.


36-3

Learning Outcomes (cont.)

36.5 Write on the patient’s chart accurately.

36.6 Carry out a patient history.

36.7 Identify parts of the health history form.

36.8 Use critical thinking skills during a patient interview.


36-4

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.


36-5

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


36-6

The Patient Interview and History (cont.)

• 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!


36-7

Patient Rights• Information is subject

to legal and ethical considerations

• American Hospital Association’s Patient’s Bill of Rights (Patient Care Partnership)

• Some patient rights– Considerate and

respectful care

– Know the identity of caregivers

– Refuse treatment– Know the costs of care– Confidentiality– Have an advance

directive


36-8

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


36-9

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


36-10

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.


36-11

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


36-12

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

2. Plan the interview– Be organized before starting the interview– Follow office policy


36-13


3. Make the patient feel at ease– Icebreakers– Appear relaxed– Eye contact

4. Ask the patient for permission to conduct the interview

– Makes the patient feel more comfortable– Emphasizes the importance of the process


36-14


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


36-15


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.)


36-16

Methods for Collecting Patient Data

Effective Characteristic

Asking 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

Restatement of 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


36-17

Methods for Collecting Patient Data (cont.)

Effective Characteristic

Encouraging 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 and provides clarification of an issue

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


36-18

Methods for Collecting Patient Data (cont.)

Ineffective Characteristic

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


36-19

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


36-20

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!


36-21

Your Role as an Observer

• Nonverbal communication may reveal more than patient’s words

• Listen attentively and observe the patient closely


36-22

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


36-23

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


36-24

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


36-25

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


36-26

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


36-27

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


36-28


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.


36-29

Six Cs of Documenting Patient Information

1. Client words

2. Clarity

3. Completeness

4. Conciseness

5. Chronological order

6. Confidential


36-30

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


36-31

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 education, follow-up


36-32

Methods for Maintaining Records

• Conventional or source-oriented medical records (SOMR) – information arranged by who provided it


36-33

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


36-34

Methods for Maintaining Records (cont.)

• Computerized medical records– Combination of

SOMR and POMR– Improved

accessibility to patient records


36-35

Terminology and Abbreviations

• Avoid incorrect use

• Refer to– Office/facility policy

– TJC “Do Not Use List”


36-36


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

H

G

F

E

D

B

A

C

ANSWER:NICE JOB!


36-37

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


36-38

The Patient’s Medical History (cont.)

• Determine chief complaint

• Interviewing technique – PQRST – Provoke or palliative– Quality or quantity– Region or Radiation– Severity Scale– Timing


36-39

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


36-40

Polypharmacy

• Document current medications– Prescription

– OTC

– Herbal

• Encourage patient to maintain a current list of medications


36-41

Health History Form

• Personal data

• Chief complaint (CC)– Reason patient made the

appointment– Short and specific

• History of present illness – detailed information about CC


36-42

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– Age at death and cause


36-43

Health History Form (cont.)

• Social and occupational history– Marital status– Occupation– Sexual orientation– Alcohol/drug use

• Review of systems – completed by practitioner


36-44


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.


36-45

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 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.


36-46

In Summary (cont.)

36.3 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.

36.4 The six C’s for writing an accurate patient history include: client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.


36-47

In Summary (cont.)

36.5 Accurate documentation requires attention to detail. The medical record is a legal document. Correct spelling and correct abbreviations are mandatory.

36.6 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.


36-48

In Summary (cont.)

36.7 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.

36.8 Critical thinking during the patient interview requires the use of open-ended questions, active listening, clarification, restatement, and reflection.


36-49

End of Chapter 36

Wisdom is to the soul what health

is to the body.

~ de Saint-Réal

interviewing the patient, taking a history, and documentation

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