Transcript Interviewing the Patient, Taking a History and Do

CHAPTER
36
Interviewing the
Patient, Taking a
History, and
Documentation
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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
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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!
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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
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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
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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
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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
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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
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36-13
The Patient Interview (cont.)
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
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-14
The Patient Interview (cont.)
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
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36-15
The Patient Interview (cont.)
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
8 Steps
(cont.)
– Summarize key points
– Ask if patient has questions or needs to
add additional information
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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
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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
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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
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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
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-20
Correct
!
Apply Your Knowledge
1.
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.”
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-21
Your Role as an Observer
• Nonverbal
communication may
reveal more than
patient’s words
• Listen attentively and
observe the patient
closely
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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
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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
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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
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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
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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
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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
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36-28
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 patient’s answer is vague and evasive. Since
multiple bruises may be a sign of abuse, you should tell the
physician of your suspicions.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-29
Six Cs of Documenting Patient Information
1.
2.
3.
4.
5.
6.
Client words
Clarity
Completeness
Conciseness
Chronological order
Confidential
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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
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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
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36-32
Methods for Maintaining Records
• Conventional or
source-oriented
medical records
(SOMR) –
information
arranged by who
provided it
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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
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36-34
Methods for Maintaining Records (cont.)
• Computerized
medical records
– Combination of
SOMR and POMR
– Improved
accessibility to
patient records
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-35
Terminology and Abbreviations
• Avoid incorrect use
• Refer to
– Office/facility policy
– TJC “Do Not Use List”
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-36
Apply Your Knowledge
Matching:
ANSWER:
___
C Precise descriptions
A. Problem list
___
E What the patient says
B. POMR
___
B Charting based on problems
C. Clarity
___
F Contains options for treatments
D. Confidentiality
___
H Arrangement based on source of information
E. Subjective data
___
A Lists patient conditions
F. Plan
___
D Essential to protect patient privacy
G. Computerized records
G Accessibility to records
___
H. SOMR
N
I
C
E
J
O
B
!
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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
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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
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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
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36-40
Polypharmacy
• Document current medications
– Prescription
– OTC
– Herbal
• Encourage patient to maintain a
current list of medications
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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
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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
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36-43
Health History Form (cont.)
• Social and occupational history
– Marital status
– Occupation
– Sexual orientation
– Alcohol/drug use
• Review of systems – completed by
practitioner
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-44
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
36-49
End of Chapter 36
Wisdom is to
the soul what
health is to
the body.
~ de Saint-Réal
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.