1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Assessment Chapter 28

2 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Holistic Care  Holistic care includes assessing the patient’s health status with physical, cognitive, psychosocial, and behavioral data.

3 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medical History: Collecting the Information  In addition to being useful for diagnosing and treating the patient, the self-history allows the patient more participation in the process.  The form may be mailed to the patient’s home before the appointment or may be completed in the office during the first visit.  If you are responsible for taking a portion of the medical history, conduct the interview in a private area free from outside interference and beyond the hearing range of other patients.

4 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medical History: Collecting the Information

5 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Collecting the Medical Information  The interview room should be physically comfortable and conducive to confidential communications.  Do not express surprise or displeasure at any of the patient’s statements.  Record the information in an organized manner, exactly as given by the patient, without opinion or interpretation.  Include CC, vital signs, weight, height, pain scale.

6 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Medical History The medical history consists of:  Patient’s database  Past medical history (PMH)  Family history (FH)  Social history (SH)  Review of systems (ROS)

7 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Understanding and Communicating with Patients  Positive reactions and interactions with patients are essential for a therapeutic relationship.  The interpersonal nature of the patient–medical assistant relationship carries with it a certain amount of responsibility to detach one’s self-interest and focus on the needs of the patients.

8 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sensitivity to Diversity  Empathy is the key to creating a caring, therapeutic environment.  Requires those interested in healthcare services to examine their own values, beliefs, and actions.

9 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Therapeutic Techniques: Active Listening Listening must be an active process in a therapeutic relationship.  Restatement  Reflection  Clarification

10 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Therapeutic Techniques: Nonverbal Communication  Approximately 90% of patient interactions occur through nonverbal language.  Successful patient interaction has congruent verbal and nonverbal messages.

11 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Preparing the Appropriate Environment  Ensure privacy.  Refuse interruptions.  Prepare comfortable surroundings.  Take judicious notes.

13 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Open-Ended Questions  Designed to give the patient the opportunity to provide additional information.  “What brings you to the doctor?”  “How have you been getting along?”  “You mentioned having dizzy spells. Tell me more about that.”

14 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Closed-Ended Questions  Asked for specific information that can be answered with only a few words.  “Do you have a headache?”  “What is your birth date?”  “Have you ever broken a bone?”

15 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Interviewing the Patient  Contract between the medical assistant and patient  Three parts  initiation or introduction  the body  the closing

16 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Interviewing the Patient

17 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Interview Barriers  Providing unwarranted assurance  Giving advice  Using medical terminology  Asking leading questions  Talking too much  Using defense mechanisms

18 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Communication across the Lifespan  Therapeutic communication techniques vary with the patient.  Be aware of how to interact most effectively with young children, adolescents, adults, and their families.  Use an age-specific approach.

19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Health History of a Child  The environment should be safe and attractive.  Do not keep children and their caregivers waiting any longer than necessary.  Do not offer a choice unless the child can truly make one. Giving a child a choice of stickers after an injection is appropriate, but asking her if she would like her shot now is not.

20 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Health History of a Child

21 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Child’s Examination  Praising the child helps decrease anxiety. When possible, direct questions to the child so he or she feels part of the process.  Involve the child by permitting him or her to manipulate the equipment.  Use your imagination to make a game of the assessment or the procedure.

22 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Child’s Examination  A typical defense mechanism seen in sick or anxious children is regression. The child may refuse to leave her mother’s lap or may want to hold a favorite toy during the procedure. Look for signs of anxiety such as thumb-sucking or rocking.

23 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Treating Adolescents  They should be involved in treatment.  Provide opportunities for a teenager to exert his or her independence.  Privacy is very important; keep body exposure to a minimum.  Want to know what is going on and what to expect; keep adolescent informed, and answer all questions.  Stress healthy life habits and decisions.

24 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Adult Patients  Patient education is extremely important.  Use lay language, and involve the patient in treatment.  Stress-related health problems are frequently seen.  Emphasize preventive healthcare measures.

25 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Recognizing and Responding to Verbal and Nonverbal Communications  The medical assistant not only must implement therapeutic communication skills but also must observe the patient to determine the patient’s message and level of understanding.

26 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Body System Assessment  Appearance  Head and neck  Eyes  Nose  Ears  Mouth and throat  Respiratory  Cardiovascular  Gastrointestinal  Urinary  Genitalia (male/female)  Lymph glands  Neurologic  Endocrine  Skin  Arms, legs, and feet

27 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Signs and Symptoms  Signs—objective findings  Something that can be measured, inspected, palpated, auscultated, or manipulated  Symptoms—subjective report from patient  Patient complaints regarding how he or she feels  Measure pain on a scale of 1 to 10  Cardinal symptoms: those most helpful in diagnosis  Functional vs. physical (organic)

28 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documentation  Accurate and complete documentation is a necessary skill.  Describe the patient’s chief complaint (C/C) and all pertinent signs and symptoms, and demonstrate the correct use of medical terminology and appropriate abbreviations.  Correct any error in the medical record according to legally approved methods.

29 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documentation

30 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Charting Methods: Problem-Oriented Medical Record (POMR)  Database  Problem list  Plan  Progress notes: use SOAPE format to define the patient’s health problems.

31 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. SOAPE Notes  S—subjective data: C/C in patient words  O—objective data: anything that is observed or measurable  A—assessment: physician’s tentative diagnosis  P—plan of care: physician documents how health problem will be managed  E—evaluation: assessment of treatment outcome

32 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Other Charting Methods  SOMR—source-oriented medical record; organizes patient data into specific sections  All information should be filed in reverse chronologic order with the most recent report or progress note on top  Progress notes documented using C/C  EMR—electronic medical record

33 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Education  The perfect time to initiate patient education is during the initial patient interview.