1. Chapter 36
Interviewing the Patient, Taking a History, and Documentation
PowerPoint® presentation to accompany:
Medical Assisting
Third Edition
Booth, Whicker, Wyman, Pugh, Thompson

2. Learning Outcomes
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 physical, mental, or substance abuse.

3. Learning Outcomes (cont.)
36.4 State the six Cs for writing an accurate patient history.
36.5 Document on the patient’s chart accurately.
36.6 Obtain a patient history.
36.7 Identify parts of the health history form.   

4. 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
How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude.

5. The Patient Interview and History
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

6. The Patient Interview and History (cont.)
Initial interview
Communication tool
More than just completing a form
Information
General health and lifestyle
Changes in health since last visit
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!

7. The Patient Interview and History (cont.)
Patient rights
Information is subject to legal and ethical considerations
AHA’s Patient’s Bill of Rights
Some patient rights
Considerate and respectful care
Know the identity of caregivers
Refuse treatment
Know the costs of care
Confidentiality
Have an advance directive

8. The Patient Interview and History (cont.)
Patient responsibilities
Provide accurate information 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 information for insurance claims

9. The Patient Interview and History (cont.)
Privacy – HIPAA
Provide patient with written notice of practices regarding use and disclosure of health information
Facilities may not use or disclose protected information for any purpose not in the privacy notice
Written authorization is required to release information
Privacy notice must be posted

10. The Patient Interview and History (cont.)
HIPAA
Enforcement began in 2003
Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail.

11. The Patient Interview and History: Interviewing Skills
Practice effective listening
Active listener – hear, think about, and respond
Be aware of nonverbal clues and body language
Have a broad knowledge base
Necessary to ask appropriate questions
Summarize to form a general picture
Verify information

12. The Patient Interview and History (cont.)
Eight steps to a successful interview
Do research before the interview
Review patient records
Be sure test and lab results are on the chart
Plan the interview
Be organized before starting the interview
Follow office policy

13. The Patient Interview and History (cont.)
Make the patient feel at ease
Icebreakers
Appear relaxed
Eye contact
Ask the patient for an interview
Makes the patient feel more comfortable
Emphasizes the importance of the process
8 Steps (cont.)

14. The Patient Interview and History (cont.)
Ensure privacy / no interruptions
Close door
Do not use “pet” names
Be respectful with sensitive topics
Watch for nonverbal cues
Watch your own nonverbal cues
8 Steps (cont.)

15. The Patient Interview and History (cont.)
Do not diagnose or give an opinion
Refer questions to physician
Do not go beyond your scope of practice
Formulate a general picture
Summarize key points
Ask if patient has questions or needs to add additional information
8 Steps (cont.)

16. The Patient Interview and History (cont.)
Methods of Collecting Patient Data
Effective
Characteristic
Asking open-ended questions
Requires more than a yes-or-no answer; results in more relevant data
Asking hypothetical questions
Enables the determination of the patient’s knowledge and whether it is accurate
Mirroring / verbalizing the implied
Restating what the patient said in your own words; stating what you believe the patient is saying
Focusing on the patient
Shows the patient you are really listening to what he is saying; maintain eye contact; be relaxed and open

17. The Patient Interview and History (cont.)
Methods of Collecting Patient Data
Effective
Characteristic
Encouraging the patient to take the lead
Motivates the patient to discuss or describe the issue in his own way
Encouraging the patient to provide additional information
Conveys sincere interest by continuing to explore topics in more detail when appropriate
Encouraging the patient to evaluate situation
Provides an idea of the patient’s point of view; allows for determination of patient’s knowledge and fears

18. The Patient Interview and History (cont.)
Methods of Collecting Patient Data
Ineffective
Characteristic
Asking closed-ended questions
Provides little information; allows no explanation of answers; require yes-or-no answers
Asking leading questions
Suggests a desired response; patient tends to agree without elaboration
Challenging the patient
Patient may feel you are disagreeing with him; he may become defensive; blocks communication
Probing
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

19. Using Critical Thinking Skills
Getting at an underlying meaning
Encourage verbalization of concerns
Mirror response
Restate patient’s comments
Verbalize what you think the patient is implying

20. Apply Your Knowledge Correct!
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.
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.”

21. Your Role as an Observer
Nonverbal communication
May reveal more than patient’s words
Listen attentively and observe the patient closely
Detect a problem that might otherwise go unnoted

22. Your Role as an Observer: Anxiety
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 information and cooperation needed

23. Your Role as an Observer: 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

24. Your Role as an Observer: 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

25. Your Role as an Observer: 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

26. Your Role as an Observer: Abuse
Battered women
Afraid to discuss injuries
Bring suspicions to physician’s attention
Encourage patient to seek help
Provide information on community resources
Abused children
Types
Physical
Emotional
Sexual
Neglected
Must be reported to authorities
Community resources

27. Your Role as an Observer: Abuse (cont.)
Elder abuse
Disabilities that make an elderly person dependent can also leave him defenseless against abuse
Suspicious injuries or signs of neglect
Report to authorities
Find out if there is an elder abuse hotline in your area

28. Your Role as an Observer: Drug and Alcohol Abuse
Substance abuse
Use of a substance in an unapproved medical manner
Not necessarily an addiction
Addiction
Physical or psychological dependence on a substance
Serious social problems
Decline in quality of work or relationships
Erratic behavior
Mood changes
Appetite loss
Tiredness
Blackouts
Tremors

29. Apply Your Knowledge Good 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?
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.
Good Answer!

30. Documenting Patient Information: Six Cs
Client words
Clarity
Completeness
Conciseness
Chronological order
Confidential

31. Documenting Patient Information (cont.)
Contents of 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

32. Documenting Patient Information (cont.)
Methods of charting
SOAP – documentation in a logical manner
Subjective data – what the patient says
Objective data – measurable information
Assessment – diagnosis or impression of problem
Plan of action – options for treatment, medications, tests, consults, patient education, follow-up

33. Documenting Patient Information (cont.)
Common methods of maintaining records
Conventional or SOMR – information arranged by who provided it
POMR
Most common
Components
Database – medical history, diagnostic and lab reports, exam reports
Problem list – problems dated and assigned a number

34. Documenting Patient Information (cont.)
POMR Components (cont.)
Diagnostic and treatment plan – tests completed and physician’s plan documented
Progress notes
Note on each recorded problem
Entered chronologically
Computerized medical records
Combination of SOMR and POMR
Improved accessibility to patient records

35. Documenting Patient Information (cont.)
Terminology and abbreviations
Avoid incorrect use
Refer to
Office / facility policy
JCAHO “Do Not Use List”
NKA
WNL
ROM
Abnl
H & P

36. Apply Your Knowledge NICE JOB! ANSWER: Matching:
___ Precise descriptions A. Problem list
___ What the patient says B. POMR
___ Charting based on problems C. Clarity
___ Contains options for treatments D. confidentiality
___ Arrangement based on source of information E. Subjective data
___ Lists patient conditions F. Plan
___ Essential to protect patient privacy G. Computerized records
___ Accessibility to records H. SOMR E B F H A D G

37. Recording the Patient’s Medical History
Includes pertinent information
Patient and patient’s family
Age, previous illness, surgical history, allergies, medications history, and family medical history
Questioning technique – PQRST
Provoke
Quality of pain
Region where located
Signs and symptoms
Time of onset

38. Recording the Patient’s Medical History (cont.)
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 information
Date

39. Recording the Patient’s Medical History (cont.)
Polypharmacy
Document current medications
Prescription
OTC
Herbal
Encourage patient to maintain a current list

40. Recording the Patient’s Medical History (cont.)
Health history form
Personal data
Chief complaint (CC)
Reason patient made the appointment
Short and specific
History of present illness
Detailed information about CC

41. Recording the Patient’s Medical History (cont.)
Health history form
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

42. Recording the Patient’s Medical History (cont.)
Health history form
Social and occupational history
Marital status
Occupation
Sexual orientation
Alcohol / drug use
Review of systems – completed by practitioner

43. Apply Your Knowledge Very Good!
In what part of the health history form do you record information about whether a patient smokes, drinks, or uses tobacco?
ANSWER: The social and occupational history portion of the health history form.
Very Good!

44. In Summary Medical assistant plays a key role in patient’s visit
Sets the tone
Makes patient feel at ease
Uses effective interview skills
Thorough history and proper documentation
Complete and accurate records
Help physician diagnose and treat the patient

45. Wisdom is to the soul what health is to the body.
End of Chapter
End of Chapter 36
Wisdom is to the soul what health is to the body.
~ de Saint-Réal