Transcript Interviewing the Patient, Taking a History and Do

PowerPoint® to accompany
Medical Assisting
Chapter 36
Second Edition
Ramutkowski  Booth  Pugh  Thompson  Whicker
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
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Interviewing the Patient, Taking a
History, and Documentation
Objectives:
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.
36-4 State the six C’s for writing an accurate patient
history.
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Patient Billing and Collections
Objectives (cont.)
36-5 Document on the patient’s chart accurately.
36-6 Identify parts of the Health History form.
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Introduction

You will prepare 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.
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The Patient Interview and History


Ask the patient specific
pieces of information
called data.
Chief complaint is
subjective statement by
patient describing the
most significant
symptoms or signs of
illness.
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Medical and Health History


Basis for all treatment
Provides information
for research, reportable
diseases and insurance
claims.


Becomes a legal record
of the treatment
rendered
Must be complete and
accurate to be a good
defense in case of legal
action.
All information regarding the patient should be
documented precisely and accurately!
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Patients Rights



All data that you obtain are subject to legal
and ethical considerations.
American Hospital Association’s Patients Bill
of Rights written in 1973 and revised in 1992.
Each state encourages healthcare workers to
be aware of and follow this document.
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Patient Responsibilities

Patients are responsibility to:



Provide information that is
accurate about past medical
conditions
Participate in decisions
Provide health care agencies
with a copy of their advance
directive.
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Patient’s Responsibilities (cont.)

Patients must:



Inform physician if they anticipate problems in
following any prescribed treatment.
Follow the physician orders for treatment.
Provide healthcare agencies with necessary
information for insurance claims and work with
healthcare facility to make arrangement to pay
fees.
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HIPAA
 Provide patient with written notice of their
practices regarding use and disclosure of
health information.
 Facilities may not use or disclose protected
information for any purpose that is not in
the privacy notice.
 Patient consent is required when
information is disclosed.
 Privacy notice must be posted.
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HIPAA (cont.)
If this act is not followed, individual
health care workers can be subject to
fines up to $250,00 and
10 years in jail.
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Interviewing Skills
To conduct an interview you will need:
 To be effective listener
 To be aware of nonverbal clues and
body language
 To use a broad knowledge base
 To summarize to form a general
picture
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Interviewing Successfully
Eight steps for interviewing success:
1. Do your research before the patient
interview
2. Plan the interview.
3. Approach the patient and request the
interview.
4. Conduct the interview in private.
5. Deal with sensitive topics with respect.
6. Do not diagnose or give diagnostic
opinions.
7. Formulate the general picture.
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Apply Your Knowledge
What type of question is the following,
“How have you been managing your
diabetes?
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Apply Your Knowledge -Answer
What type of question is the following,
“How have you been managing your
diabetes?
An open-ended question which will allow
the patient to explain the situation
more clearly.
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Apply Your Knowledge #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.”
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Apply Your Knowledge #2 -Answer
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.”
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
Listening attentively and
observing the patient
closely may help detect a
problem that might
otherwise go unnoted.
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Anxiety


Common emotional
response when seeing a
physician (white coat
syndrome.)
Mild anxiety – patient
has heightened ability
to observe and make
connections.


Severe anxiety- patient
has difficulty focusing
on details, feels
panicky and virtually
helpless.
Lack of focus will
hinder your ability to
get the information and
cooperation needed.
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Depression

Common symptoms






Profound sadness
Fatigue
Difficulty in falling asleep
Loss of appetite
Loss of energy
Occurs in late adolescence, middle age,
and after retirement.
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Physical and Psychological Abuse



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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Signs of Physical Abuse






Child’s failure to thrive
Severe dehydration or underweight
Delayed medical attention
Hair loss
Drug use
Genital injuries
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Abused Elderly



Disabilities that make an elderly person
dependent can also leave him defenseless
against abuse.
May have suspicious injuries or show
signs of neglect
Find out if there is an elder abuse hot-line
in your area.
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Drug and Alcohol Abuse




Patient may behave erratically, have
mood changes , suffer loss of appetite and
be constantly tired.
Patient may have no apparent signs or
symptoms at first, but may have bruises
and trembling hands.
Patient may suffer blackouts
Patient may become secretive and guilty
about drinking
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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?
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Apply Your Knowledge -Answer
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?
Bruises may be a sign of abuse. You
should notify the physician immediately
if you suspect any type of abuse.
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The Six C’s of Charting
1. Client words must be recorded exactly.
2. Clarity is essential when describing the patient’s
condition.
3. Completeness is required.
4. Conciseness can save time and space.
5. Chronological order and date all entries.
6. Confidentiality to protect the patient’s privacy.
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Contents of the Patient’s Charts








Registration Form
Patient medical history
Test results
Records from other physician or hospitals
Physician’s diagnosis and treatment plan
Operative reports
Informed consents
Discharge summary and correspondences
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Charting using SOAP




S – Subjective data: thoughts, feelings, and
chief complaints of the patient
O – Objective data: readily apparent and
measurable data
A – Assessment: physician’s diagnosis and
impression
P – Plan of action: options for treatment
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Recording the Patient’s
Medical History


Includes pertinent information about the
patient and the patient’s family.
Age, previous illness, surgical history,
allergies, medications history and family
medical history.
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Methods of Charting



Conventional or Source-Oriented Medical
Records (SOMR) – arrange according to who
provided the information.
Problem – Oriented Medical Record (POMR)
more extensively and includes databases,
problem list and plans of care.
Computerized Medical Records – uses both
SOMR & POMR from a computer terminal.
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Health History Form







Personal Data
Chief Complaint
History of Present Illness
Past Medical History
Family History
Social and Occupational History
Review of Systems
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Apply Your Knowledge
In what part of the health history form would
you record information about whether a
patient smokes, drinks, or uses tobacco?
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Apply Your Knowledge -Answer
In what part of the health history form would
you record information about whether a
patient smokes, drinks, or uses tobacco?
The social and occupational history portion of
the health history form.
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Summary
Medical Assistant
Taking a thorough history and using proper
documentation methods will allow you to ensure that
the patient’s records are complete and accurate.
Using interviewing skills effectively will help make
the interview productive as well as comfortable for
the patient.
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End of Chapter
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