Transcript Ch. 18 PPT File - Northwest ISD Moodle

Chapter 18:Chapter XX:
Chapter
Title
Medical History and Patient
Assessment
Learning Outcomes
 Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
 1. Spell and define key terms
 2. Recognize barriers to communication
 3. Identify techniques for overcoming communication barriers
 4. Give examples of the type of information included in each
section of the patient history
 5. Identify guidelines for conducting a patient interview using
principles of verbal and nonverbal communication
 6. Differentiate between subjective and objective information
 7. Discuss open-ended and closed-ended questions and explain
when to use each type during the patient interview
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Learning Outcomes (cont'd.)
 Psychomotor Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
 1. Use feedback techniques to obtain patient information





including the following: (a) reflection, (b) restatement, and (c)
clarification
2. Use medical terminology correctly and pronounced
accurately to communicate information to providers and
patients
3. Respond to nonverbal communication
4. Obtain and record a patient history (Procedure 18-1)
5. Accurately document a chief complaint and present illness
(Procedure 18-2)
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Learning Outcomes (cont'd.)
 Affective Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
 1. Incorporate critical thinking skills when performing patient




assessment
2. Demonstrate (a) empathy, (b) active listening, and (c)
nonverbal communication
3. Demonstrate sensitivity to patients rights
4. Demonstrate principles of self-boundaries
5. Demonstrate respect for individual diversity including (a)
gender, (b) race, (c) religion, (d) age, (e) economic status, and
(f) appearance
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Learning Outcomes (cont'd.)
 ABHES Competencies
 1. Be impartial and show empathy when dealing with patients
 2. Interview effectively
 3. Recognize and respond to verbal and nonverbal
communication
 4. Obtain chief complaint, recording patient history
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Introduction
To diagnose a patient’s present
illness, the physician needs the
patient’s past and current health
information. As a professional
medical assistant, you are often
responsible for obtaining this
information as part of the medical
history and assessment.
medical history:
record containing
information about a
patient’s past and
present health status
assessment:
process of gathering
information about
the patient and the
presenting condition
The medical history is a record containing information about a patient’s past and
present health status, the health status of related family members, and relevant
information about a patient’s social habits.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History
 Methods of Collecting Information



Physician (be ready to assist)
Medical assistant + physician
Patient or medical assistant fills out form
To complete the patient’s medical history, you and the physician work
cooperatively with the patient.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History (cont’d.)
Back to Learning Outcomes
Copyright © 2016 Wolters Kluwer • All Rights Reserved
The Medical History (cont’d.)
 Elements of the Medical History


Form contains confidential
information protected by HIPAA
Information collected:
o Identifying demographic data
o Name
o Contact/insurance info
o SS#
o Marital status
o Gender
o Race
Health Insurance Portability
and Accountability Act
(HIPAA): federal law,
originally passed as the
Kassebaum-Kennedy Act, that
requires all health care settings
to ensure
privacy and security of patient
information. Also requires
health insurance to be
accessible for working
Americans and available when
changing employment
demographic: relating to the
statistical characteristics of
populations
The medical history forms used by the office may vary with the practice
specialty, but most forms are composed of these common elements: identifying data
(database), past history, review of systems, family history, and social history.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History (cont’d.)
A sample medical history form (front).
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History (cont’d.)
A sample medical history form (back).
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History (cont’d.)
 Past history (PH):
Childhood diseases
 Prior health status, surgeries, medications, illnesses,
hospitalizations
 Existing illness and medications, allergies,
immunizations
 Review of systems (ROS):
o Discuss each body system
o Specific symptoms

Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
The Medical History (cont’d.)
 Family history (FH):
Health status of parents, siblings,
grandparents
o Familial disease
o Hereditary disease
 Social history (SH):
o Lifestyle, occupation, education,
marital status
o Diet, alcohol/tobacco use, sexual
history
o
familial: referring to a
disorder that tends to occur
more often in a family than
would be anticipated solely
by chance
hereditary: referring to
traits or disorders that are
transmitted from parent to
offspring
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Question
An elderly patient asks Steve what is the
difference between the past history and the
family history. How would Steve explain the
difference?
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Answer
The past history summarizes the patient’s prior
health status, whereas the family history
summarizes the health status of the patient’s
parents, siblings, and grandparents.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Conducting the Patient Interview
 Preparing for the Interview




Goal — obtain accurate and relevant patient information
First step — prepare for interview
Know active listening techniques:
o Reflecting
o Paraphrasing, summarizing
o Asking for examples
o Asking questions
o Allowing silence
Communication also includes observation
As a medical assistant, your primary goal during a patient interview is to obtain
accurate and pertinent information.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Conducting the Patient Interview (cont’d.)
 Review medical history
 Conduct interview in private
 Observe patient — note
objective condition:
o Physical — general
appearance
o Emotional —
crying/tearful, lethargic
o Avoid diagnostic terms
such as depressed,
abused
Conduct the patient interview in a
private office or exam room.
Before you start interviewing the patient, make sure you are familiar with the
medical history form and any previous medical history provided by the patient.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Conducting the Patient Interview (cont’d.)
 Introducing Yourself





Give your name and title
State purpose of interview
Emphasize confidentiality
Behave professionally and respectfully — build
trust
Display caring and empathy
Under no circumstance should you identify yourself as a nurse because it is
unethical and illegal to give the patient a false impression of your credentials.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Conducting the Patient Interview (cont’d.)
 Barriers to Communication






Language — unfamiliar with English
Hearing — impaired
Cognitive — impaired
Avoid jargon or technical terminology
Face patient
Maintain eye contact
Note the patient’s verbal and nonverbal behavior during the interview and adjust
your questioning if necessary.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Question
Steve takes a few minutes to look over the
medical history form before going into the
exam room to interview a new patient. Why is it
important to review the medical history form
before beginning the interview?
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Answer
You should be familiar with the medical history
form before beginning the patient interview to
promote smooth communication during the
interview.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Question
Why should you let the patient know that any
information shared during the interview will be
kept confidential?
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Answer
It is important to let the patient know that any
information shared during the interview will be
kept confidential. Understanding this enables
patients to trust in the medical staff and
encourages them to share important
information that allows the physician to
provide better care for the patient.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Assessing the Patient
 Signs and Symptoms

Signs:
o Rash
o Bleeding
o Coughing
o Vital signs
o Found during physician examination
signs: objective
indications of
disease or bodily
dysfunction
as observed or
measured by the
health care
professional
Signs are objective information that can be observed or perceived by someone
other than the patient.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Assessing the Patient (cont’d.)
 Symptoms:
o
o
o
o
o
Pain
Headache
Nausea
Dizziness
Can be observed in patient
reactions — wincing, gagging,
holding onto objects while dizzy
symptoms:
subjective indications
of disease or bodily
dysfunction as
sensed by the patient
Symptoms, or subjective information, are indications of disease or changes in
the body as sensed by the patient.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Assessing the Patient (cont’d.)
 Chief Complaint (CC) and Present
Illness (PI)
 Chief complaint:
o Includes signs and symptoms
o Documented in medical record
as a progress report
chief complaint
(CC): main reason
for the visit to the
medical office
Open-ended questions allow the patient to answer with more than one or two
words.
The CC, which is one statement describing the signs and symptoms that led the
patient to seek medical care, is documented in the patient’s medical record at each
visit.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Assessing the Patient (cont’d.)
 Present illness:
o
More specific information:
• Chronology
• Location
• Severity
• Self-treatment (over-the-counter
drugs, homeopathic remedies)
• Quality
• Duration
over-the-counter (OTC):
available without a
prescription; includes herbal
and vitamin supplements
homeopathic: referring to
an alternative type of
medicine in which patients
are treated with small doses
of substances that produce
similar symptoms and use
the body’s own healing
abilities
Avoid suggesting answers with questions such as “Is the pain sharp?” or “Is the
pain worse when you walk?”
In addition, do not coax patients by making suggestions of symptoms you might
expect them to have based on the chief complaint.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Assessing the Patient (cont’d.)
 Open-ended — patient answers in more than a few words
 Should be asked before closed-ended questions
 Patient’s description in own words
 Help develop chief complaint
 Closed-ended — patient answers in one or two words
 Should be asked after open-ended questions
 Obtain specific data about present illness
 Avoid questions that suggest answers
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Question
Explain the difference between a sign and a
symptom, and give one example of each.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes
Checkpoint Answer
A sign is an objective (observable or
measurable) indication of disease. An example
of a sign is a patient’s blood pressure,
temperature reading, or noting a laceration or
rash on the patient’s skin.
A symptom is a subjective indication of disease
that is felt or noticed by the patient but not
directly observable or measurable by the
medical assistant or physician. Examples of
symptoms include headache, nausea, and pain.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Back to Learning Outcomes