© 2009 The McGraw-Hill Companies, Inc. All rights reserved Interviewing the Patient, Taking a History, and Documentation PowerPoint® presentation to accompany:

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

Interviewing the Patient, Taking a Interviewing the Patient, Taking a History, and DocumentationHistory, and Documentation

PowerPoint® presentation to accompany:

Medical AssistingThird Edition

Booth, Whicker, Wyman, Pugh, Thompson

36-2


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.

36-3


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.

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.)

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!

36-7



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

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



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


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.

36-11


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

36-12



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 an interview Makes the patient feel more comfortable Emphasizes the importance of the process

8 Steps (cont.)

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

8 Steps (cont.)

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 of Collecting Patient Data

Effective 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

36-17




Effective 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

36-18




Ineffective 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

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 Detect a problem that might

otherwise go unnoted

36-22


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

36-23


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

36-24


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

36-25


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

36-26


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

36-27


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

36-28


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

36-29


Apply Your KnowledgeWhile 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.

36-30


Documenting Patient Information: Six Cs

1. Client words

2. Clarity

3. Completeness

4. Conciseness

5. Chronological order

6. Confidential

36-31


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

36-32



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

36-33



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

36-34



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

36-35



Terminology and abbreviations Avoid incorrect use Refer to

Office / facility policy

JCAHO “Do Not Use List”

36-36


Apply Your KnowledgeMatching:

___ 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


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

36-38


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

36-39



Polypharmacy Document current

medications Prescription OTC Herbal

Encourage patient to maintaina current list

36-40


Health history form Personal data Chief complaint (CC)

Reason patient made the appointment

Short and specific

History of present illness Detailed information about CC


36-41


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


36-42


Health history form Social and occupational history

Marital status Occupation Sexual orientation Alcohol / drug use

Review of systems – completed by practitioner


36-43


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.

36-44


In Summary Medical assistant plays a key role in patient’s

visit Sets the tone Makes patient feel at ease Uses effective interview skills

Thorough history and proper documentation Complete and accurate records Help physician diagnose and treat the patient

36-45


End of Chapter

Wisdom is to the soul what health

is to the body.

~ de Saint-Réal

© 2009 The McGraw-Hill Companies, Inc. All rights reserved Interviewing the Patient, Taking a History, and Documentation PowerPoint® presentation to accompany:

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