After completing chapter 36, you will be able to: Identify the skills necessary to conduct a patient interview; recognize the signs of anxiety; depression; and physical, mental, or substance abuse; use the six Cs for writing an accurate patient history; carry out a patient history using critical thinking skills;...
CHAPTER 36 Patient Interview and History 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 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 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 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! Patient Rights, Responsibilities, and Privacy • Information is subject to legal and ethical considerations • The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities 36-6 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 36-7 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 36-8 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 36-9 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 36-10 36-42 Methods of Charting (cont.) • Computerized medical records – Combination of SOMR and POMR – Improved accessibility to patient records Common Chart Terminology and Abbreviations • Use only approved abbreviations • Refer to – Office/facility policy – TJC “Do Not Use List” 36-43 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 Problem list B POMR C Clarity D Confidentiality E Subjective data A Lists patient conditions _ F Plan D Essential to protect patient privacy _ G Computerized records G Accessibility to records _ H SOMR N I C E J O B ! 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 Recording the Patient’s Medical History (cont.) • Determine chief complaint • Interviewing technique – PQRST – Provoke or palliative – Quality or Quantity – Region or Radiation – Severity scale – Timing 36-46 Recording the Patient’s Medical History (cont.) • Key correct information into the EHR • Pay attention to spelling • Use only approved abbreviations • Select the correct item from menus 36-47 36-48 Progress Notes • Guidelines – Arrange in reverse chronological order – Initial / sign entries – Patient identification information – Date & time 36-49 Polypharmacy • Document current medications • Encourage patient to maintain a current list of medications 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 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 36-52 Health History Form (cont.) • Social and occupational history – Marital status – Occupation – Sexual orientation – Alcohol/drug use • Review of systems – completed by practitioner 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 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 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 36-56 End of Chapter 36 Wisdom is to the soul what health is to the body ~ de Saint-Réal ... writing an accurate patient history 36. 4 Carry out a patient history using critical thinking skills 36- 3 Introduction • The medical assistant – Prepares the patient and the patient s chart – Records... 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 36- 4 The Patient Interview. .. for appointment – Routine check up – Illness ~ chief complaint 36- 5 The Patient Interview and History (cont.) • Medical and health history – Basis for all treatment rendered – Information for •