Interviewing the Patient, Taking a History, and Documentation

PowerPoint presentation to accompany:

Medical Assisting
Third Edition

Booth, Whicker, Wyman, Pugh, Thompson

2009 The McGraw-Hill Companies, Inc. All rights reserved

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Learning Outcomes
36.1 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 patients 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 patients 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 practitioners examination process

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

Medical and health history

Basis for all treatment rendered Information for

General health and lifestyle Changes in health since last visit

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

Some patient rights

Information is subject to legal and ethical considerations AHAs Patients Bill of 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 physicians 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 (cont.)

HIPAA

Enforcement began in 2003 Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail.

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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 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

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The Patient Interview and History (cont.)

3.

Make the patient feel at ease

Icebreakers Appear relaxed Eye contact

8 Steps (cont.)

4.

Ask the patient for an interview

Makes the patient feel more comfortable Emphasizes the importance of the process
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The Patient Interview and History (cont.)

5.

Ensure privacy / no interruptions

Close door Do not use pet names

8 Steps (cont.)

6.

Be respectful with sensitive topics

Watch for nonverbal cues Watch your own nonverbal cues

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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 Steps (cont.)

8.

Formulate a general picture

Summarize key points Ask if patient has questions or needs to add additional information
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The Patient Interview and History (cont.)

Methods of Collecting Patient Data Effective Characteristic
Asking open-ended questions Asking hypothetical questions Mirroring / verbalizing the implied Focusing on the patient Requires more than a yes-or-no answer; results in more relevant data Enables the determination of the patients knowledge and whether it is accurate Restating what the patient said in your own words; stating what you believe the patient is saying 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 Data Effective Characteristic
Encouraging the patient to take the lead Encouraging the patient to provide additional information Motivates the patient to discuss or describe the issue in his own way Conveys sincere interest by continuing to explore topics in more detail when appropriate

Encouraging the patient to evaluate situation

Provides an idea of the patients point of view; allows for determination of patients knowledge and fears

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The Patient Interview and History (cont.)

Methods of Collecting Patient Data Ineffective Characteristic
Asking closed-ended questions Asking leading questions Challenging the patient Probing Provides little information; allows no explanation of answers; require yes-or-no answers Suggests a desired response; patient tends to agree without elaboration Patient may feel you are disagreeing with him; he may become defensive; blocks communication Once patient has finished, probing may make him defensive

Agreeing / disagreeing with Implies that the patient is either right or patient wrong; block to communication
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Using Critical Thinking Skills

Getting at an underlying meaning

Encourage verbalization of concerns Mirror response Restate patients comments Verbalize what you think the patient is implying

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Apply Your Knowledge

1.

Correct!

What type of question is the following: How have you been managing your diabetes?

ANSWER: An open-ended question which will allow the patient to explain the situation more clearly. 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.
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Your Role as an Observer

Nonverbal communication

May reveal more than patients 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

Severe anxiety

White coat syndrome Heightened ability to observe and make connections

Mild 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 Signs of substance morning Loss of appetite Loss of energy

Occurs in late adolescence, middle age, and after retirement

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

Childs 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

Abused children

Afraid to discuss injuries Bring suspicions to physicians attention Encourage patient to seek help Provide information on community resources

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

Substance abuse

Decline in quality of work or relationships Erratic behavior Mood changes Appetite loss Tiredness Blackouts Tremors

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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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 patients answer is vague and evasive. Since multiple bruises may be a sign of abuse, you should tell the physician of your suspicions.

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Documenting Patient Information:

Six Cs
1. 2. 3. 4.

5.
6.

Client words Clarity Completeness Conciseness Chronological order 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 Physicians 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 physicians 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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Apply Your Knowledge

Matching:

ANSWER:
A. Problem list B. POMR C. Clarity D. confidentiality E. Subjective data F. Plan

___ C Precise descriptions ___ E What the patient says B Charting based on problems ___ ___ F Contains options for treatments ___ H Arrangement based on source of information ___ A Lists patient conditions ___ D Essential to protect patient privacy ___ G Accessibility to records

N I C E

G. Computerized records H. SOMR

J O B !

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Recording the Patients Medical History

Includes pertinent information

Patient and patients 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 Patients 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 Patients Medical History (cont.)

Polypharmacy

Document current medications

Prescription OTC Herbal

Encourage patient to maintain a current list

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Recording the Patients Medical History (cont.)

Health history form

Personal data Chief complaint (CC)

Reason patient made the appointment Short and specific Detailed information about CC

History of present illness

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Recording the Patients Medical History (cont.)

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
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Recording the Patients Medical History (cont.)

Health history form

Social and occupational history

Marital status Occupation Sexual orientation Alcohol / drug use

Review of systems completed by practitioner

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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.

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In Summary

Medical assistant plays a key role in patients visit

Sets the tone Makes patient feel at ease Uses effective interview skills
Complete and accurate records Help physician diagnose and treat the patient
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Thorough history and proper documentation

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End of Chapter

Wisdom is to the soul what health is to the body.

~ de Saint-Ral

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