Chapter 36 - Interviewing the patient. After completing chapter 36, you will be able to: Name the skills necessary to conduct a patient interview; explain the procedure for conducting a patient interview; recognize the signs of anxiety; depression; and physical, mental, or substance abuse;...
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 Interviewing the Patient, Taking a History, and Documentation Objectives: 361 Name the skills necessary to conduct a patient interview 362 Explain the procedure for conducting a patient interview 363 Recognize the signs of anxiety, depression and physical, mental or substance abuse 364 State the six C’s for writing an accurate patient history Patient Billing and Collections Objectives (cont.) 365 Document on the patient’s chart accurately 366 Identify parts of the Health History form 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 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 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! 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 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 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 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 10 Signs of Physical Abuse Child’s failure to thrive Severe dehydration or underweight Delayed medical attention Hair loss Drug use Genital injuries 22 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 hotline in your area 23 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 24 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? 25 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. 26 The Six C’s of Charting Client words must be recorded exactly Clarity is essential when describing the patient’s condition Completeness is required Conciseness can save time and space Chronological order and date all entries Confidentiality to protect the patient’s privacy. 27 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 28 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 29 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 30 Methods of Charting Conventional or SourceOriented 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 31 Health History Form Personal Data Chief Complaint History of Present Illness Past Medical History Family History Social and Occupational History Review of Systems 32 Apply Your Knowledge In what part of the health history form would you record information about whether a patient smokes, drinks, or uses tobacco? 33 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 34 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 35 End of Chapter 36 ...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 ... 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 Patient Billing and Collections Objectives (cont.) 36 5 Document on the patient’s chart accurately... patient and the patient’s family Age, previous illness, surgical history, allergies, medications history and family medical history 30 Methods of Charting Conventional or SourceOriented Medical