Transcript File

Chapter 23
The Patient History and
Documentation
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Preparing for the Patient
• Make certain of the following:
– Examination room is ready
– All supplies are available
– You are familiar with the patient’s chart
• Bring the patient from the reception area to
where the interview will take place
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Preparing for the Patient
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Preparing for the Patient
• Introduce yourself and speak plainly
– Determine if any assistance is needed for the patient
– If necessary, offer assistance with your friendly
greeting
– Accompany patient to the examination room and close
the door
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Preparing for the Patient
• Introduce yourself and
speak plainly
– Seat the patient comfortably
and sit face-to-face to begin
the interview
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Preparing for the Patient
• Introduce yourself and speak plainly
– Build rapport with the patient
– Use the patient’s name often, making certain you
pronounce it correctly
– Think globally as the interview begins
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The Purpose of the Medical History
• Basis for all treatment rendered by physician or
any other provider
• Helps to guide treatment for patient
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The Purpose of the Medical History
• Chart
– Gives base for statistical analysis
– Serves as a legal record
– Should include everything concerning patient treatment
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A Cross-Cultural Model
• Every patient interview is cross-cultural
• Health and illness are inseparable from
social/cultural beliefs
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A Cross-Cultural Model
• Patient’s chief
concern: the illness
• Patient’s idea of
treatment success:
managing illness
• Provider’s chief
concern: disease
• Provider’s idea of
treatment success:
control disease
problems
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A Cross-Cultural Model
• Questions to ask patients
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What do you think caused your problem?
When do you think it started?
What effect does it have on you?
What are your concerns from this problem?
What kind of treatment do you expect?
• Respect patient’s perspective
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Patient Information Forms
• Demographic data form
– Name; address; home, work, cell telephone numbers;
date of birth
– Social Security number, insurance data, emergency
contact person
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Patient Information Forms
• Financial information form
– Financial policy of clinic, billing, insurance, finance
charges
– Minor patients, missed appointments
– Patient signs and receives a copy
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Patient Information Forms
• Privacy information form
– Since 2004 any release of patient PHI must be disclosed
– See http://www.hhs.gov for details
– Civil penalties for failure to comply
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Patient Information Forms
• Release of information form
– Authorizes release of health care information to specific
individuals
– Must be in writing, signed, and dated
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Patient Information Forms
• Medical history form
– Present health history, including why patient is being
seen
– Past health history, personal and family
– Social history including marital status, sexual
orientation, occupation
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Patient Information Forms
• Medical history form
– Military service dates and assignment
– Body systems review/questionnaire
– Medications currently taken, including over-thecounter, prescription, and herbal
– Provider’s review of system (ROS)
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Patient Information Forms
• Computerized health history
– Patient-generated
– Provider-generated
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The Patient Intake Interview
• Interacting with the patient
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Put patient at ease
Guide conversation
Keep on track
Explain terms as needed
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The Patient Intake Interview
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The Patient Intake Interview
• Interacting with the patient
– Remain professional
– Update history as needed
– Remain calm and not embarrassed by any of patient’s
comments
– Note the chief complaint
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The Patient Intake Interview
Click Here to play the video
Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
The Patient Intake Interview
• Displaying cultural awareness
– Patient who does not speak English
– Patient who may be deaf
– If interpreter is needed; complete business associate
contract (HIPAA)
– Cultural barriers addressed
– Patient may have other special needs
– Medical assistant must listen carefully and
communicate effectively
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The Patient Intake Interview
• Be sensitive to patient’s needs
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Patient may be frightened, hostile, or depressed
Be aware of nonverbal and verbal communication
Know when touch is appropriate
Respect boundaries
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The Patient Intake Interview
• Be sensitive to patient’s needs
– Be patient and understanding
– Calm upset patients
– Patient may express a particular need
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The Patient Intake Interview
• Dealing with sensitive topics
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Ask questions in later stages of interview
Use casual direct eye contact without staring
Pose questions in matter-of-fact tone
Adopt nonjudgmental demeanor
Use “normalize” technique when appropriate
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Communication Across the Lifespan
• Patient’s age is important in
communications
– Infants
• Communicate with two patients: parent and infant
– Older children
• Provider may wish to examine alone
– Teenagers
• Sets the stage for care in adulthood
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Communication Across the Lifespan
• Patient’s age is important in
communications
– Older adults
• May be accompanied by another person, either by choice or
because of necessity
– May have a HIPAA waiver signed by patient when a
second person is in attendance
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The Medical Health History
• Personal data from demographic form
• Chief complaint
• Present illness
– Medications
– Allergies
– Other providers or alternative therapy practitioners
being seen
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The Medical Health History
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Medical history
Family history
Social and occupational history
Review of systems by physician or provider
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SOAP/SOAPER
• SOAPER method of charting
– S = Subjective data, patient’s complaint in their own words
– O = Objective, observable, measurable findings
– A = Assessment, probable diagnosis based on subjective and
objective factors
– P = Plan for treatment, medications, instructions, return visit
information
– E = Education for the patient
– R = Response of patient to education and care given
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CHEDDAR
• CHEDDAR method of charting
– C = Chief complaint, presenting problems, subjective information
– H = History
• Social and physical of presenting problem; contributing data
– E = Examination, body systems review
– D = Details of problem(s) and complaint(s)
– D = Drugs and dosages; list of current medications, dosages,
frequency
– A = Assessment; diagnostic evaluation, further testing,
medications
– R = Return visit, if applicable
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Chief Complaint (CC)
• Noted in as few words as possible; can
quote the patient
• Subjective data; be specific about cause,
time of onset, and complaint
• Characteristics may include:
– Location
– Radiation
– Quality
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Chief Complaint (CC)
• Characteristics may include:
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Severity
Associated symptoms
Aggravating factors
Alleviating factors
Setting and timing
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Present Illness
• Usually reflected in CC
• May be expanded using the “a through h”
classification above
• May include other problems experienced,
medications, and allergies
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Medical History
• Surgeries
• Allergies and medications (reviewed at
every visit)
• Health problems
• Major illnesses
• Release of information form
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Family History
• Familial and hereditary health problems
• Age of family members; cause of death and
age at the time
• Clues to patient’s present condition
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Social History
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Spouse/partner status
Sexual habits
Hobbies
Use of alcohol, recreational drugs, tobacco
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Social History
• Lifestyles/behaviors that put patient at risk
• Home environment assessment questions
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Review of Systems (ROS)
• Orderly and systemic check of each part of
anatomy
• Document positive and negative findings
• Used to make differential/clinical diagnosis
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Review of Systems (ROS)
• Patient’s record and its importance
• Contents of the medical record
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Patient’s Record and its Importance
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Confidential information
Foundation for planning patient care
Basis for communication among care givers
Legal document
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HIPAA Compliance Focuses on
Three Vulnerable Areas
• Paper record storage and computer/server
areas
• Fax machines
• Workstations
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Contents of Medical Records
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Informed consent forms
Physical examination outcomes
Laboratory and diagnostic test results
Diagnosis and plan of treatment
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Contents of Medical Records
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Surgical reports
Progress reports
Follow-up care
Telephone calls related to care
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Contents of Medical Records
• Discharge summary
• Other communications from providers,
laboratories, etc.
• Patient’s records from other providers
• Medication history
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Continuity of Care Record (CCR)
• Developed by a number of medical groups
• Makes it easier to transport patient medical
information among providers
• Improves continuity of care and reduces
errors
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Continuity of Care Record (CCR)
• Includes the following:
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Patient and provider information
Insurance data
Patient’s health status
Recent care given
Recommendations for future care
Reason for referral
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Continuity of Care Record (CCR)
• Most likely would include advanced
directives
• To be completed by physicians and
providers, nurses, medical assistants,
ancillary providers
• Can be transferred electronically
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Methods of Charting/Documentation
• Source-oriented medical records
– Chronological set of notes for each visit
– May be typed by medical transcriptionist from
provider’s dictation
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Methods of Charting/Documentation
• Problem-oriented medical records
– Database: history and examination results (core of
record)
– Problem List: identified with assigned numbers
– Diagnostic/Treatment Plan: documented
chronologically for each problem
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EMRs
• Mandated by 2010
• Can be a part of TPMS
– Available 24 hours a day
– Can be accessed from outside location
– Available to more than one person at a time
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EMRs
• Can be a part of TPMS
– Storage is simple
– Fewer errors than in handwritten data
– Software capability of “flagging” queries to providers
• Charting rules are similar to those in the
paper record
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Rules of Charting
• Charting required for every patient contact
related to care
– Must be accurate, clear, complete, timely, entered
properly
– “Act not charted” is considered an “act not done”
– Abbreviations used in charting kept to a minimum
– Medical record must be understandable to any person
reading it
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Rules of Charting
• Chart organization
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Must be kept in orderly, predetermined fashion
Chronological order
Manual record uses both sides of chart for specific data
Contents of miscellaneous section
Specific order to be understood by each member of the
clinic staff
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