CHAPTER 36 Patient Interview and History 36-2 Learning Outcomes (cont.) 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Recognize.

CHAPTER

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36Patient Interview

and History

36-2


Learning Outcomes (cont.)

36.1 Identify the skills necessary to conduct a patient interview.

36.2 Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.

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

36.4 Carry out a patient history using critical thinking skills

36-3


Introduction

• The medical assistant– Prepares the patient

and the patient’s chart

– Conducts a patient interview

– Records the necessary medical history

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

difference in the patient’s attitude.

36-4


The Patient Interview and History • Patient interview

– First step in examination process

– Establishes a relationship

– Exchange information

• Establish reason for appointment

– Routine check up

– Illness ~ chief complaint

36-5


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!

36-6


Patient Rights, Responsibilities, and Privacy

• Information is subject to legal and ethical considerations

• The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities

36-7


Patient Rights, Responsibilities, and Privacy (cont.)

• 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



• Some patient responsibilities: – Provide accurate information

– Participate in healthcare decisions

– Provide a copy of their advance directive

– Follow physician’s orders

– Provide information for insurance claims

36-9



• HIPAA – Enforcement began in

2003

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

36-10



• HIPAA requires

– Written notice of privacy practices

– No use or disclosure of protected information for purposes not in the privacy notice

– Written authorization to release information

– Posting the privacy notice

36-11


Communicating with Professionalism

• Communication skills– Language skills

and body language

– Impact your career

– Think before you speak or react

36-12


Interviewing Skills

• Practice effective listening

• Be aware of nonverbal clues and body language

• Have a broad knowledge base

• Summarize to form a general picture

36-13


Interviewing Skills

• Practice effective listening – Listen for details

– General view of situation

– Active listening• Look at patient• Pay attention• Provide feedback -

restatement

• Be aware of nonverbal clues and body language

36-14


Interviewing Skills (cont.)

• Have a broad knowledge base

• Summarize to form a general picture

– Consider the importance information obtained

– Repeat back a summary of the information

36-15


Interviewing Successfully

1. Do research before the interview– Review medical record– Note issues that may impact health– Be sure appropriate reports are in the record

2. Plan interview – follow office policies

36-16


Interviewing Successfully (cont.)

3. Request the interview– Makes the patient feel more comfortable

– Emphasizes the importance of the process

4. Make the patient feel at ease– Icebreakers

– Sit and appear relaxed

36-17



5. Ensure privacy/no interruptions– Private area or close door

– Develop a rapport with the patient

6. Be respectful with sensitive topics– Watch for nonverbal cues

– Watch your own nonverbal cues

36-18



7. Do not diagnose or give an opinion– Refer questions to physician– Remember your scope of practice

8. Formulate a general picture– Summarize key points– Ask if patient has questions or needs to

add additional information

36-19



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

Mirroring – restatement of what the patient said in your own words. Verbalizing the implied – stating what you believe the patient is saying

Focusing on the patient

Shows the patient you are really listening to what he is saying

36-20



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 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

36-21



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

36-22



Ineffective CharacteristicProbing 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

36-23


Apply Your Knowledge

ANSWER: An open-ended question which will allow the patient to explain the situation more clearly.

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

1. What are four skills you will need to conduct a successful interview? ANSWER:

Effective listening

Being aware of nonverbal cues

Having a broad knowledge base

Summarizing to form a general picture

Correct!

36-24


Your Role as an Observer

• Nonverbal communication

may reveal more than patient’s words

• Listen attentively and observe the patient closely

36-25


Anxiety

• Common emotional response

• Mild anxiety – heightened focus

• Severe anxiety – difficulty focusing

• Either a heightened focus or a lack of focus can hinder the interview process

36-26


Depression

• Classic symptoms – Profound sadness

– Fatigue

• Additional problems – Difficulty falling asleep or getting up in the

morning

– Loss of appetite

– Loss of energy

36-27


Depression

• In adolescence – Difficult to distinguish from addiction and

substance abuse– Notify physician if any of these are suspected

• Middle age – triggered by life events

• Elderly – mistaken for senility

36-28


Physical and Psychological Abuse

• Physical, psychological, or both

• Suspect abuse – If the patient speaks in a

guarded way

– Unlikely explanation for an injury

36-29


Physical and Psychological Abuse (cont.)

• Signs of abuse– Head injuries/skull fractures

– Burns that appear deliberate

– Broken bones

– Bruises – multiple; in various stages of healing

36-30


Physical and Psychological Abuse (cont.)

• Other signs of abuse– A child’s failure to thrive – Severe dehydration or underweight – Delayed medical attention – Hair loss – Drug use – Genital injuries

36-31


The Interview and Abuse

• Women, children, and elderly

– More likely to be abused

– Observe carefully during interview

– Report suspected abuse to physician or supervisor

– Have a list of hotline numbers available

36-32


The Interview and Abuse (cont.)

• Women– Often feel shame – Listen carefully, be nonjudgmental

• Children – Observe for nonverbal cues– Watch relationship between child and caregiver

• Elderly – observe carefully

36-33


Drug and Alcohol Abuse

• Substance abuse and addiction– Symptoms vary with substance abused

– Cause • Decline in work and relationships• Erratic behavior• Mood changes• Loss of appetite• Constant tiredness

36-34



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.

36-35


Documenting Patient Information

• Client’s words – record exactly

• Clarity – use medical terminology and precise descriptions

• Completeness – fill in forms

36-36


Documenting Patient Information (cont.)

• Conciseness

• Chronological order – date all entries

• Confidentiality – protects patient’s privacy

36-37


Contents of Patient Charts

• Registration form

• Patient medical history

• Test results

• Records from other physicians or hospitals

36-38


Contents of Patient Charts

• Physician’s diagnosis and treatment plan

• Operative reports

• Informed consents

• Discharge summary

• Correspondence

36-39


Methods of Charting

• SOAP

– Subjective data

– Objective data

– Assessment

– Plan of action

36-40


Methods of Charting (cont.)

• Source-oriented medical records (SOMR)

– Conventional – Information is arranged

by who provided it

36-41


• Problem-oriented medical records (POMR)– Database ~ foundation of the POMR record

– Problem list – each problem is dated and numbered

– Diagnostic and treatment plan

– Progress notes – chronological order


36-42



• Computerized medical records

– Combination of SOMR and POMR

– Improved accessibility to patient records

36-43


Common Chart Terminology and Abbreviations

• Use only approved abbreviations

• Refer to– Office/facility policy

– TJC “Do Not Use List”

36-44



Matching:

___ Precise descriptions

___ What the patient says

___ Charting based on problems

___ Contains options for treatments

___ Arrangement based on source of information

___ Lists patient conditions

___ Essential to protect patient privacy

___ Accessibility to records

H

G

F

E

D

B

A

C

ANSWER:NICE JOB!

A. Problem list

B. POMR

C. Clarity

D. Confidentiality

E. Subjective data

F. Plan

G. Computerized records

H. SOMR

36-45


Recording the Patient’s Medical History

• Includes pertinent information – About the patient and patient’s family medical

history

– Age, surgical history, allergies, medications

– Must be complete and accurate

36-46


Recording the Patient’s Medical History (cont.)

• Determine chief complaint

• Interviewing technique – PQRST

– Provoke or palliative

– Quality or Quantity

– Region or Radiation

– Severity scale

– Timing

36-47


Recording the Patient’s Medical History (cont.)

• Key correct information into the EHR

• Pay attention to spelling

• Use only approved abbreviations

• Select the correct item from menus

36-48


Progress Notes

• Guidelines– Arrange in reverse chronological order

– Initial / sign entries

– Patient identification information

– Date & time

36-49


Polypharmacy

• Document current medications

• Encourage patient to maintain a current list of medications

36-50


Health History Form

• Personal data

• Chief complaint (CC)– Reason patient made the appointment– Short and specific

• History of present illness – detailed information about CC

36-51


Health History Form (cont.)

• Past medical history– All health problems– Medications– Allergies

• Family history– May help determine cause of current problem– Ages, medical conditions– Age at death and cause

36-52


Health History Form (cont.)

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

• Review of systems – completed by practitioner

36-53



When recording the patient’s chief complaint, you will probably need to ask more questions. What tool can you use to help you ask the appropriate questions?

ANSWER: The interviewing technique – PQRST, will help you to remember the types of questions that are appropriate for the problem.

36-54


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 Anxiety can range from a heightened ability to observe to a difficulty in being able to focus. Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and lost of appetite. Abuse can be physical or psychological.

36-55


In Summary (cont.)

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

36.4 When obtaining a patient history, you can use open-ended questions, active listening, clarification, restatement, reflection, and the PQRST interview technique; review the information obtained, determine the importance, and then document the facts accurately

36-56


End of Chapter 36

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

~ de Saint-Réal

CHAPTER 36 Patient Interview and History 36-2 Learning Outcomes (cont.) 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Recognize.

Documents

patient responsibilities

history patient interview

history slide

accurate patient history

patient rights considerate

patient care partnership

additional information

relaxed slide