CHAPTER 36 Interviewing the Patient, Taking a History, and Documentation 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. 36-2 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. 36-3 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 36-4 How you conduct yourself during the first few moments with the patient can make a major difference in the patient s attitude. 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 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 must be documented precisely and accurately! 36-6 1
36-7 36-8 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 Patient Responsibilities Provide accurate 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 for insurance claims Patient Privacy 36-9 Patient Privacy (cont.) 36-10 HIPAA Provide patient with written notice of practices regarding use and disclosure of health Facilities may not use or disclose protected for any purpose not in the privacy notice Written authorization is required to release Privacy notice must be posted HIPAA Enforcement began in 2003 Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail. 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 36-11 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 36-12 2
36-13 36-14 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 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 The Patient Interview (cont.) 36-15 Methods for Collecting Patient Data 36-16 7. Do not diagnose or give an opinion Refer questions to physician Do not go beyond your scope of practice 8 Steps 8. Formulate a general picture (cont.) Summarize key points Ask if patient has questions or needs to add additional Effective Asking open-ended questions Asking hypothetical questions Mirroring/verbalizing the implied Focusing on the patient Characteristic 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 Restatement of what the patient said in your own words; stating what you believe the patient is saying Shows the patient you are really listening to what he is saying; maintain eye contact; be relaxed and open 36-17 36-18 Methods for Collecting Patient Data (cont.) Methods for Collecting Patient Data (cont.) Effective Characteristic Ineffective Characteristic Encouraging the patient to take the lead Motivates the patient to discuss or describe the issue in his own way Asking closed-ended questions Provides little ; allows no explanation of answers; require yes-or-no answers Encouraging the patient to provide additional Encouraging the patient to evaluate situation 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 Asking leading questions Challenging the patient Probing Suggests a desired response; patient tends to agree without elaboration Patient may feel you are disagreeing with him; he may become defensive; blocks communication 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 3
Using Critical Thinking Skills 36-19 Apply Your Knowledge Correct! 36-20 Getting at an underlying meaning Encourage verbalization of concerns Mirror response Restate patient s comments Verbalize what you think the patient is implying 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. Your Role as an Observer 36-21 Anxiety 36-22 Nonverbal communication may reveal more than patient s words Listen attentively and observe the patient closely 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 and cooperation needed 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 36-23 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 36-24 4
36-25 36-26 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 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 Drug and Alcohol Abuse 36-27 Apply Your Knowledge 36-28 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 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. Six Cs of Documenting Patient Information 1. Client words 2. Clarity 3. Completeness 4. Conciseness 5. Chronological order 6. Confidential 36-29 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 36-30 5
Method of Charting SOAP documentation in a logical manner Subjective data what the patient says Objective data measurable Assessment diagnosis or impression of problem Plan of action options for treatment, medications, tests, consults, patient education, follow-up 36-31 Methods for Maintaining Records Conventional or source-oriented medical records (SOMR) arranged by who provided it 36-32 36-33 36-34 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 Methods for Maintaining Records (cont.) Computerized medical records Combination of SOMR and POMR Improved accessibility to patient records Terminology and Abbreviations Avoid incorrect use Refer to Office/facility policy TJC Do Not Use List 36-35 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 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 36-36 N I C E J O B! 6
36-37 36-38 The Patient s Medical History Includes pertinent Patient and patient s family Age, previous illness, surgical history, allergies, medications history, and family medical history Must be complete and accurate The Patient s Medical History (cont.) Determine chief complaint Interviewing technique PQRST Provoke or palliative Quality or quantity Region or Radiation Severity Scale Timing 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 Date 36-39 Polypharmacy Document current medications Prescription OTC Herbal Encourage patient to maintain a current list of medications 36-40 Health History Form Personal data Chief complaint (CC) Reason patient made the appointment Short and specific History of present illness detailed about CC 36-41 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 36-42 7
Health History Form (cont.) Social and occupational history Marital status Occupation Sexual orientation Alcohol/drug use 36-43 Apply Your Knowledge In what part of the health history form do you record about whether a patient smokes, drinks, or uses tobacco? ANSWER: The social and occupational history portion of the health history form. 36-44 Review of systems completed by practitioner In Summary 36-45 In Summary (cont.) 36-46 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. 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. 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 obtained, determine the importance, and then document the facts accurately. 36-47 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. 36-48 8
End of Chapter 36 36-49 Wisdom is to the soul what health is to the body. ~ de Saint-Réal 9