Presentation on theme: "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."— Presentation transcript:
CHAPTER 36 Patient Interview and History
36-2 Learning Outcomes (cont.) 36.1 Identify the skills necessary to conduct a patient interview Recognize the signs of anxiety; depression; and physical, mental, or substance abuse. 36.3Use the six Cs for writing an accurate patient history Carry out a patient history using critical thinking skills
36-3 Introduction The medical assistant –Prepares the patient and the patients chart –Conducts a patient interview –Records the necessary medical history How you conduct yourself during the first few moments with the patient can make a major difference in the patients 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!
36-6 Patient Rights, Responsibilities, and Privacy Information is subject to legal and ethical considerations The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities
36-7 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
36-8 Patient Rights, Responsibilities, and Privacy (cont.) Some patient responsibilities: –Provide accurate information –Participate in healthcare decisions –Provide a copy of their advance directive –Follow physicians orders –Provide information for insurance claims
36-9 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.
36-10 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
36-11 Communicating with Professionalism Communication skills –Language skills and body language –Impact your career –Think before you speak or react
36-12 Interviewing Skills Practice effective listening Be aware of nonverbal clues and body language Have a broad knowledge base Summarize to form a general picture
36-13 Interviewing Skills Practice effective listening –Listen for details –General view of situation –Active listening Look at patient Pay attention Provide feedback - restatement Be aware of nonverbal clues and body language
36-14 Interviewing Skills (cont.) Have a broad knowledge base Summarize to form a general picture –Consider the importance information obtained –Repeat back a summary of the information
36-15 Interviewing Successfully 1.Do research before the interview –Review medical record –Note issues that may impact health –Be sure appropriate reports are in the record 2.Plan interview – follow office policies
36-16 Interviewing Successfully (cont.) 3.Request the interview –Makes the patient feel more comfortable –Emphasizes the importance of the process 4.Make the patient feel at ease –Icebreakers –Sit and appear relaxed
36-17 Interviewing Successfully (cont.) 5.Ensure privacy/no interruptions –Private area or close door –Develop a rapport with the patient 6.Be respectful with sensitive topics –Watch for nonverbal cues –Watch your own nonverbal cues
36-18 Interviewing Successfully (cont.) 7.Do not diagnose or give an opinion –Refer questions to physician –Remember your scope of practice 8.Formulate a general picture –Summarize key points –Ask if patient has questions or needs to add additional information
36-19 Interviewing Successfully (cont.) EffectiveCharacteristic 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 patients knowledge and whether it is accurate Mirroring / verbalizing the implied Mirroring – restatement of what the patient said in your own words. Verbalizing the implied – stating what you believe the patient is saying Focusing on the patient Shows the patient you are really listening to what he is saying
36-20 Interviewing Successfully (cont.) EffectiveCharacteristic 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 and provides clarification of an issue Encouraging the patient to evaluate situation Provides an idea of the patients point of view; allows for determination of patients knowledge and fears. Uses reflection to form a thought, idea, or opinion
36-21 Interviewing Successfully (cont.) IneffectiveCharacteristic 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
36-22 Interviewing Successfully (cont.) IneffectiveCharacteristic ProbingOnce patient has finished, probing may make him defensive Agreeing/disagreeing with patient Implies that the patient is either right or wrong; block to communication
36-23 Apply Your Knowledge ANSWER: An open-ended question which will allow the patient to explain the situation more clearly. 2.What type of question is the following: How have you been managing your diabetes? 1.What are four skills you will need to conduct a successful interview? ANSWER: Effective listening Being aware of nonverbal cues Having a broad knowledge base Summarizing to form a general picture Correct!
36-24 Your Role as an Observer Nonverbal communication m ay reveal more than patients words Listen attentively and observe the patient closely
36-25 Anxiety Common emotional response Mild anxiety – heightened focus Severe anxiety – difficulty focusing Either a heightened focus or a lack of focus can hinder the interview process
36-26 Depression Classic symptoms –Profound sadness –Fatigue Additional problems –Difficulty falling asleep or getting up in the morning –Loss of appetite –Loss of energy
36-27 Depression In adolescence –Difficult to distinguish from addiction and substance abuse –Notify physician if any of these are suspected Middle age – triggered by life events Elderly – mistaken for senility
36-28 Physical and Psychological Abuse Physical, psychological, or both Suspect abuse –If the patient speaks in a guarded way –Unlikely explanation for an injury
36-29 Physical and Psychological Abuse (cont.) Signs of abuse –Head injuries/skull fractures –Burns that appear deliberate –Broken bones –Bruises – multiple; in various stages of healing
36-30 Physical and Psychological Abuse (cont.) Other signs of abuse –A childs failure to thrive –Severe dehydration or underweight –Delayed medical attention –Hair loss –Drug use –Genital injuries
36-31 The Interview and Abuse Women, children, and elderly –More likely to be abused –Observe carefully during interview –Report suspected abuse to physician or supervisor –Have a list of hotline numbers available
36-32 The Interview and Abuse (cont.) Women –Often feel shame –Listen carefully, be nonjudgmental Children –Observe for nonverbal cues –Watch relationship between child and caregiver Elderly – observe carefully
36-33 Drug and Alcohol Abuse Substance abuse and addiction –Symptoms vary with substance abused –Cause Decline in work and relationships Erratic behavior Mood changes Loss of appetite Constant tiredness
36-34 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? ANSWER: The patients answer is vague and evasive. Since multiple bruises may be a sign of abuse, you should tell the physician of your suspicions.
36-35 Documenting Patient Information Clients words – record exactly Clarity – use medical terminology and precise descriptions Completeness – fill in forms
36-36 Documenting Patient Information (cont.) Conciseness Chronological order – date all entries Confidentiality – protects patients privacy
36-37 Contents of Patient Charts Registration form Patient medical history Test results Records from other physicians or hospitals
36-38 Contents of Patient Charts Physicians diagnosis and treatment plan Operative reports Informed consents Discharge summary Correspondence
36-39 Methods of Charting SOAP –Subjective data –Objective data –Assessment –Plan of action
36-40 Methods of Charting (cont.) Source-oriented medical records (SOMR) –Conventional –Information is arranged by who provided it
36-41 Problem-oriented medical records (POMR) –Database ~ foundation of the POMR record –Problem list – each problem is dated and numbered –Diagnostic and treatment plan –Progress notes – chronological order Methods of Charting (cont.)
36-42 Methods of Charting (cont.) Computerized medical records –Combination of SOMR and POMR –Improved accessibility to patient records
36-43 Common Chart Terminology and Abbreviations Use only approved abbreviations Refer to –Office/facility policy –TJC Do Not Use List
36-44 Apply Your Knowledge Matching: ___ Precise descriptions ___ What the patient says ___ Charting based on problems ___ Contains options for treatments ___ Arrangement based on source of information ___ Lists patient conditions ___ Essential to protect patient privacy ___ Accessibility to records H G F E D B A C ANSWER: NICE JOB!NICE JOB! A.Problem list B.POMR C.Clarity D.Confidentiality E.Subjective data F.Plan G.Computerized records H.SOMR
36-45 Recording the Patients Medical History Includes pertinent information –About the patient and patients family medical history –Age, surgical history, allergies, medications –Must be complete and accurate
36-46 Recording the Patients Medical History (cont.) Determine chief complaint Interviewing technique – PQRST –Provoke or palliative –Quality or Quantity –Region or Radiation –Severity scale –Timing
36-47 Recording the Patients Medical History (cont.) Key correct information into the EHR Pay attention to spelling Use only approved abbreviations Select the correct item from menus
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 patients 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 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 clients words, clarity, completeness, conciseness, chronological order, and confidentiality 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