Transcript The Profession of Medical Assisting

CHAPTER
36
Patient Interview
and History
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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
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36-3
Introduction
• The medical assistant
– Prepares the patient
and the patient’s chart
– Records the
necessary medical
history
– Conducts a patient
interview
How you conduct yourself during the first few
moments with the patient can make a major
difference in the patient’s attitude.
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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
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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!
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36-6
Patient Rights, Responsibilities, and
Privacy
• Information is subject to legal and ethical
considerations
• The Patient Care Partnership:
Understanding Expectations, Rights, and
Responsibilities
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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
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36-8
Patient Rights, Responsibilities, and
Privacy (cont.)
• 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
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36-9
Patient Rights, Responsibilities, and
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.
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36-10
Patient Rights, Responsibilities, and
Privacy (cont.)
•
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
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36-11
Communicating with Professionalism
• Communication
skills
– Language skills
and body language
– Impact your career
– Think before you
speak or react
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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
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36-13
Interviewing Skills
• Practice effective
listening
– Listen for details
• Be aware of
nonverbal clues
and body language
– General view of
situation
– Active listening
• Look at patient
• Pay attention
• Provide feedback restatement
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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
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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
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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
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36-17
Interviewing Successfully (cont.)
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
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36-18
Interviewing Successfully (cont.)
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
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36-19
Interviewing Successfully (cont.)
Effective
Characteristic
Asking openended questions
Asking
hypothetical
questions
Mirroring /
verbalizing the
implied
Requires more than a yes-or-no answer;
results in more relevant data
Enables the determination of the patient’s
knowledge and whether it is accurate
Focusing on the
patient
Shows the patient you are really listening
to what he is saying
Mirroring – restatement of what the
patient said in your own words.
Verbalizing the implied – stating what
you believe the patient is saying
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36-20
Interviewing Successfully (cont.)
Effective
Characteristic
Encouraging the
patient to take the
lead
Encouraging the
patient to provide
additional
information
Encouraging the
patient to
evaluate situation
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 and provides clarification
of an issue
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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36-21
Interviewing Successfully (cont.)
Ineffective
Characteristic
Asking closed-ended Provides little information; allows no
questions
explanation of answers; require yesor-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
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36-22
Interviewing Successfully (cont.)
Ineffective
Characteristic
Probing
Once patient has finished, probing
may make him defensive
Agreeing/disagreeing Implies that the patient is either
with patient
“right” or “wrong”; block to
communication
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36-23
Apply Your Knowledge
Correct!
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
2. 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.
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36-24
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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36-25
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
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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
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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
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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
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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
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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
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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
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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
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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
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36-34
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.
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36-35
Documenting Patient Information
• Client’s words – record exactly
• Clarity – use medical
terminology and precise descriptions
• Completeness – fill in forms
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36-36
Documenting Patient Information (cont.)
• Conciseness
• Chronological order – date all entries
• Confidentiality – protects patient’s privacy
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36-37
Contents of Patient Charts
• Registration form
• Patient medical history
• Test results
• Records from other physicians
or hospitals
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36-38
Contents of Patient Charts
• Physician’s diagnosis and treatment plan
• Operative reports
• Informed consents
• Discharge summary
• Correspondence
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36-39
Methods of Charting
• SOAP
– Subjective data
– Objective data
– Assessment
– Plan of action
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36-40
Methods of Charting (cont.)
• Source-oriented medical
records (SOMR)
– Conventional
– Information is arranged
by who provided it
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36-41
Methods of Charting (cont.)
• 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
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36-42
Methods of Charting (cont.)
• Computerized medical
records
– Combination of SOMR
and POMR
– Improved accessibility
to patient records
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
36-43
Common Chart Terminology and
Abbreviations
• Use only approved
abbreviations
• Refer to
– Office/facility policy
– TJC “Do Not Use List”
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
36-44
Apply Your Knowledge
Matching: ANSWER:
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
___
A. Problem list
B. POMR
C. Clarity
D. Confidentiality
E. Subjective data
F. Plan
G. Computerized records
H. SOMR
N
I
C
E
J
O
B
!
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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
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Recording the Patient’s Medical History
36-46
(cont.)
• Determine chief complaint
• Interviewing technique – PQRST
– Provoke or palliative
– Quality or Quantity
– Region or Radiation
– Severity scale
– Timing
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Recording the Patient’s Medical History
36-47
(cont.)
• Key correct information into the EHR
• Pay attention to spelling
• Use only approved abbreviations
• Select the correct item from menus
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36-48
Progress Notes
• Guidelines
– Arrange in reverse chronological order
– Initial / sign entries
– Patient identification information
– Date & time
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36-49
Polypharmacy
• Document current medications
• Encourage patient to maintain a
current list of medications
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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
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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
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36-52
Health History Form (cont.)
• Social and occupational history
– Marital status
– Occupation
– Sexual orientation
– Alcohol/drug use
• Review of systems – completed by
practitioner
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36-53
Apply Your Knowledge
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.
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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.
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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
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36-56
End of Chapter 36
Wisdom is to
the soul what
health is to
the body.
~ de Saint-Réal
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.