1. Patient Interview and History36
Patient Interview and History

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

3. Introduction The medical assistant
Prepares the patient and the patient’s chart
Conducts a patient interview
Records the necessary medical history
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
The medical assistant is the first contact with the patient in the exam room.
Conducting the patient interview and recording the necessary medical history are essential to the practitioner’s exam process.
How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude.

4. The Patient Interview and History
First step in examination process
Establishes a relationship
Exchange information
Establish reason for appointment
Routine check up
Illness ~ chief complaint
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Well-conducted initial interview helps establish a beneficial relationship between you and the patient.
Subsequent interviews with established patients may take less time.
All patient interviews require good communication skills.
Reason for the appointment
Routine checkup – ask the patient about general health and lifestyle and about any changes in health status since the last visit
Medical problem
Ask about his or her symptoms
Determine the patient’s chief complaint which is a subjective statement made by the patient describing his or her most significant symptoms.

5. The Patient Interview and History (cont.)
Medical and health history
Basis for all treatment rendered
Information for
Research
Reportable diseases
Insurance claims
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Refer to OCL for Recording a Chief Complaint
The chart is a legal record of treatment provided. All information must be documented precisely and accurately!

6. Patient Rights, Responsibilities, and Privacy
Information is subject to legal and ethical considerations
The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Most states have adopted a version of the American Hospital Association’s (AHA) Patient’s Bill of Rights, written in 1973 and revised in 1992.
The AHA has now replaced this bill of rights with “The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities,”

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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Additional patient rights
Receive complete and current information concerning diagnosis, treatment, and prognosis
Receive information necessary to give informed consent
Have an advance directive
Obtain reasonable responses to requests for services
Obtain information about his or her health care, be allowed to review his or her medical record, and have any information explained or interpreted
Know whether treatment is experimental
Expect reasonable continuity of care
Be informed of business relationships between hospital and others that may influence treatment
Know which hospital policies and practices relate to patient care, treatment, and responsibilities
Be informed of available resources for resolving disputes, grievances, conflicts
Examine his or her bill and have it explained, and be informed of available payment methods

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 physician’s orders
Provide information for insurance claims
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Medical assistants also should know that patients have certain responsibilities when they seek medical care. Patients are responsible for:
Providing information about past illnesses, hospitalizations, medications, and other matters related to their health status. If an incorrect diagnosis is made because a patient fails to give the physician the proper information, the physician is not liable.
Participating in decision making by asking for additional information about their health status or treatment when they do not fully understand information and instructions.
Providing healthcare agencies with a copy of their written advance directive if they have one.
Informing physicians and other caregivers if they anticipate problems in following a prescribed treatment,
Following the physician’s orders for treatment. If a patient willfully or negligently fails to follow the physician’s instructions, that patient has little legal recourse.
Providing healthcare agencies with necessary information for insurance claims and working with the healthcare facility to make arrangements to pay fees when necessary.

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.
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.

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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
If the Health Insurance Portability and Accountability Act (HIPAA) is not followed, individual healthcare workers can be subject to fines up to $250,000 and 10 years in jail.
The privacy standards of this act ensure the following:
Healthcare facilities must provide patients with a written notice of their practices regarding the use and disclosure of all individually identifiable health information.
Healthcare facilities may not use or disclose protected health information for any purpose that is not in the privacy notice.
Patient consent is required when protected information is used or disclosed for purposes of treatment, payment, or health operations.
Written authorization is required for other types of disclosures.
Hospitals must make the privacy notice available either prior to, or at the time of, the delivery of care.
A privacy notice must be posted in a clear and prominent location within the hospital facility.

11. Communicating with Professionalism
Communication skills
Language skills and body language
Impact your career
Think before you speak or react
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Your overall professionalism and poise can be a direct result of your verbal communication skills.
Use of improper language skills or sloppy body language, gives the patient the perception that you are not educated or intelligent.
Communication skills will have a direct impact on your career.
Think before you speak or react and you will learn to avoid communication pitfalls.

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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.

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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Listening attentively
Hear, think about, and respond to what the patient has said. This technique is called active listening.
Active listener – looks at the patient, pays attention, and provides feedback.
Restatement – repeat what the patient says, in your own words to help ensure that you have understood the meaning of the patient’s words.
Being Aware of Nonverbal Clues and Body Language
Nonverbal communication often communicates more than words could ever say.
Pay attention to the patient’s facial expression and how much the patient guards the area in question.

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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Using a Broad Knowledge Base
You must have a broad knowledge base to ask questions that will elicit the most meaningful information about the patient.
Take every opportunity to expand your knowledge base.
Summarizing to Form a General Picture
The interview provides both subjective and objective data.
You must consider the relative importance of each piece of information so that you can summarize the data to formulate a general picture of the patient.
Ensure that all important data are recorded.
Repeating the summary may jog their memory.

15. Interviewing Successfully
Do research before the interview
Review medical record
Note issues that may impact health
Be sure appropriate reports are in the record
Plan interview – follow office policies
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
One of the main goals of the patient interview is to give the patient an opportunity to fully explain the reason for the current office visit.
These eight steps will help you conduct a successful interview.
Doing Research Before the Patient Interview
Review the patient’s medical record for history, medications, and chronic problems.
Make sure that all currently ordered diagnostic testing, laboratory work, and consultation results are in the chart.
Planning the Interview
Develop an interview plan by having a general idea of the questions you will ask.
This helps you maintain your focus and ensures that you will obtain all the necessary information.
Planning for the types of information that you need to collect will save time for the visit itself.

16. Interviewing Successfully (cont.)
Request the interview
Makes the patient feel more comfortable
Emphasizes the importance of the process
Make the patient feel at ease
Icebreakers
Sit and appear relaxed
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Approaching the Patient and Requesting the Interview
Ask the patient for permission before conducting the interview.
It also makes the patient feel more like a participant.
Making the Patient Feel at Ease
Icebreakers put the patient at ease and create a relaxed atmosphere.
Sit with the patient and appear relaxed.
This helps the patient relax and encourages a more open and comfortable interview.
It also facilitates eye contact
If you are entering data into an electronic record, do NOT pay more attention to inputting information into the computer than looking at and speaking with your patient.

17. Interviewing Successfully (cont.)
Ensure privacy/no interruptions
Private area or close door
Develop a rapport with the patient
Be respectful with sensitive topics
Watch for nonverbal cues
Watch your own nonverbal cues
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Conducting the Interview in Private Without Interruptions
Show the patient to a private room or area or close the door if the patient is already in a private room.
Listen carefully to the patient’s responses – you may need ask questions other than those in your interview plan.
Develop a rapport with the patient
Keep atmosphere relaxed
Do not rush
Maintain eye contact
Use patient’s name in conversation
Avoid interruptions.
Do not use “pet names” for your patients.
Dealing with Sensitive Topics with Respect
Approach these topics gently so that the patient does not feel threatened
Know when to stop – watch for verbal and nonverbal clues
Be conscious of your own body language.

18. Interviewing Successfully (cont.)
Do not diagnose or give an opinion
Refer questions to physician
Remember your scope of practice
Formulate a general picture
Summarize key points
Ask if patient has questions or needs to add additional information
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Avoiding Making a Diagnosis or Giving a Diagnostic Opinion
If the patient asks for your opinion about a diagnosis, explain that the physician should be asked about diagnoses.
Never go beyond your scope of practice or job description.
Formulating the General Picture
Summarize the key points of the interview.
Remain alert and organized but flexible.
Refer to Procedure 36-1 Using Critical Thinking Skills During an Interview

19. Interviewing Successfully (cont.)
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
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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Refer to Table 36-1 Methods of Collecting Patient Data.

20. Interviewing Successfully (cont.)
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 and provides clarification of an issue
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. Uses reflection to form a thought, idea, or opinion
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Refer to Table 36-1 Methods of Collecting Patient Data.
Clarification – increased understanding of the problem.
Reflection is when a thought, idea, or opinion is formed as a result of deeper thought, in this case stimulated by a question.

21. Interviewing Successfully (cont.)
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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Refer to Table 36-1 Methods of Collecting Patient Data.

22. Interviewing Successfully (cont.)
Ineffective
Characteristic
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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
Refer to Table 36-1 Methods of Collecting Patient Data.
Refer to CONNECT to see a video about Using Critical Thinking Skills During an Interview .

23. Apply Your Knowledge
Correct!
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
Learning Outcome: 36.1 Identify the skills necessary to conduct a patient interview.
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.

24. Your Role as an Observer
Nonverbal communication may reveal more than patient’s words
Listen attentively and observe the patient closely
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Listening attentively and observing the patient closely may help you detect a problem that might otherwise go unnoted.

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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Some patients respond with anxiety to a specific fear, such as fear of pain.
Others simply feel anxious when they are in an unfamiliar situation (white-coat syndrome).
Anxiety varies from mild to severe.
Mild anxiety – a heightened ability to observe and to make connections.
Severe anxiety – difficulty focusing on details, feels panicky, and is virtually helpless.
A heightened focus or a lack of focus in a patient can hinder your ability to get the information and cooperation you need.
When patient is anxious
Allow the patient to describe feelings.
Postpone talking about a subject until patient is calmer.
Give support in nonverbal ways by trying to make the patient as comfortable as possible.

26. Depression Classic symptoms Additional problems Profound sadness
Fatigue
Additional problems
Difficulty falling asleep or getting up in the morning
Loss of appetite
Loss of energy
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Depression can be difficult to recognize, as some of its symptoms are the same as those of many common illnesses.
Many patients with major depression develop great skill in hiding depression or are unaware they are suffering from it.

27. Depression In adolescence Middle age – triggered by life events
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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Depression occurs most frequently during late adolescence, in middle age, and after retirement.
In adolescence, all three conditions may exist simultaneously.
Substance abuse refers to the use of a substance, even an over-the-counter drug, in a way that is not medically approved.
Addiction refers to a physical or psychological dependence on a substance.
Refer to Caution: Handle with Care: Signs of Depression, Substance Abuse, and Addiction in Adolescents
In the middle aged
Triggered by life events like financial troubles or death of a family member.
Sometimes confused with midlife crises.
In the elderly – often mistaken for senility

28. Physical and Psychological Abuse
Physical, psychological, or both
Suspect abuse
If the patient speaks in a guarded way
Unlikely explanation for an injury
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Abuse can involve people from all walks of life and of all ages.
Be alert for possible abuse.

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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.

30. Physical and Psychological Abuse (cont.)
Other signs of abuse
A child’s failure to thrive
Severe dehydration or underweight
Delayed medical attention
Hair loss
Drug use
Genital injuries
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.

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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.

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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Women
85% of victims of domestic violence are women and those ages 20 to 24 are at the greatest risk.
May make excuses for their abuser or refuse to discuss it.
Reasons for staying in the abusive relationship include fear of the abuser, threats of suicide by the abuser, financial dependence, lack of housing options, low self-esteem, and isolation.
Be kind, supportive, and nonjudgmental while interviewing a woman you suspect may be a victim of abuse.
Children
Consider the child first even as you are asking the parent or caregiver about the child’s condition.
Communicate with the child and observe for nonverbal signs of pain or other problems.
Watch for any problems in the relationship between the child and caregiver.
The Elderly – always observe the elderly patient for nonverbal signs of problems, such as grimacing, foul odors, or bruising.

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
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Substance abuse and addiction to drugs or alcohol are serious social problems.
Symptoms of substance abuse or addiction differ from drug to drug.
Refer to Table 36-2 Symptoms Associated with Commonly Abused Drugs.
Someone who is abusing alcohol may have no apparent signs or symptoms at first.
As time goes on, a person may suffer from blackouts, become secretive and guilty about drinking and deny that there is a problem.
If healthcare team members recognize a problem, they should try to persuade the patient to seek help.

34. 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.
Learning Outcomes: Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
Good Answer!

35. Documenting Patient Information
Client’s words – record exactly
Clarity – use medical terminology and precise descriptions
Completeness – fill in forms
Learning Outcome: Use the six Cs for writing an accurate patient history.
Remember that the patient chart is a legal document and can be used as evidence in a court of law.
To help ensure that you record patient data accurately, follow the six Cs of charting.
Client’s words
Record them exactly; use quotation marks
They may help the doctor uncover clues to use in diagnosing the patient’s condition.
Clarity – essential to describing the patient’s condition.
Completeness – all the forms used in the patient record must be complete.

36. Documenting Patient Information (cont.)
Conciseness
Chronological order – date all entries
Confidentiality – protects patient’s privacy
Learning Outcome: Use the six Cs for writing an accurate patient history.
Conciseness – saves time and space when you are recording information.
Chronological order
Date all entries in patient records when documenting patient care. This information can be used for legal questions regarding medical services.
Most charts are arranged in reverse chronological order with the most recent information on top.
Confidentiality
Without written permission you may not
Discuss a patient’s records
Forward them to another office
Fax them
Show them to anyone except the doctor
The only exception is when the records must be sent to ensure continuity of care of the patient and the patient is unable to grant permission.

37. Contents of Patient Charts
Registration form
Patient medical history
Test results
Records from other physicians or hospitals
Learning Outcome: Use the six Cs for writing an accurate patient history.
Whether electronic or paper, all records contain standard information.
Date and initial every entry in the patient record.
The patient registration form carries the date of the patient’s current visit and generally lists the patient’s age, address, medical insurance, occupation, education, racial or ethnic background, marital status, number of children, and nearest relative.
Patient medical history includes the chief complaint, history of the present illness, past medical history family history, social and occupational history and may include the
results of a general physical exam.
Test results include those performed in the office and those received from other physicians, hospitals, or independent laboratories.
Records from other physicians or hospitals are accompanied by a copy of the patient’s written authorization to release the records.

38. Contents of Patient Charts
Physician’s diagnosis and treatment plan
Operative reports
Informed consents
Discharge summary
Correspondence
Learning Outcome: Use the six Cs for writing an accurate patient history.
Operative reports include a record of all procedures, surgeries, follow-up care, and additional notes the physician makes regarding the patient’s case.
Informed consent forms verify that the patient has understood the treatment offered and the possible outcomes or side effects of it.
A discharge summary form is used to summarize the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered; and the disposition, or outcome, of the case.
Correspondence with or about the patient is marked or stamped with the date the physician’s office received the document.
Some medical offices also keep a separate log of telephone calls to and from the patient.
The physician usually initials reports before they are filed.
Refer to OLC for Building the Past Medical History and Family Health History

39. Methods of Charting SOAP Subjective data Objective data Assessment
Plan of action
Learning Outcome: Use the six Cs for writing an accurate patient history.
Most methods of documentation are based on the SOAP method.
Subjective data
Obtained from conversation with the patient or an attending family member.
Includes thoughts, feelings, perceptions, and the chief complaint.
Objective data – readily apparent and measurable.
Assessment. – the physician’s diagnosis or impression of the patient’s problem.
Plan of action – options for treatment, the type of treatment chosen, medications, tests, consultations, patient education, and follow-up.

40. Methods of Charting (cont.)
Source-oriented medical records (SOMR)
Conventional
Information is arranged by who provided it
Learning Outcome: Use the six Cs for writing an accurate patient history.
There are three common methods for maintaining notes.
Conventional or source-oriented medical records (SOMR) – information is arranged according to who supplied it.
Problem-oriented medical records (POMR)
Computerized medical records

41. Methods of Charting (cont.)
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
Learning Outcome: Use the six Cs for writing an accurate patient history.
Problem-oriented medical records (POMR)
Used more extensively by large clinics or practices
Includes a problem list that is dated and numbers are assigned to problem.
Problems are identified by a number throughout the record until resolved.
Four components:
Database – the patient’s medical history, diagnostic and laboratory results, and physical exam reports.
Problem list – each patient condition or problem is listed individually, assigned a number, and dated.
Diagnostic and treatment plan – laboratory and other diagnostic tests are completed and the physician’s treatment plan for the condition.
Progress notes – notes are entered chronologically on every condition or problem recorded on the problem list. They include the chief complaint, problems, conditions, treatments, and responses to treatments.

42. Methods of Charting (cont.)
Computerized medical records
Combination of SOMR and POMR
Improved accessibility to patient records
Learning Outcome: Use the six Cs for writing an accurate patient history.
Uses a combination of SOMR and POMR but provides accessibility by the physician or other healthcare workers at any time from a computer terminal.
This accessibility enhances the patient’s continuity of care between departments and specialty physicians in other practices.

43. Common Chart Terminology and Abbreviations
NKA
Use only approved abbreviations
Refer to
Office/facility policy
TJC “Do Not Use List”
WNL
H & P
Abnl
Learning Outcome: Use the six Cs for writing an accurate patient history.
Abbreviations used must be accepted by the facility where you are employed as well as The Joint Commission (TJC).
To help reduce medical errors, The Joint Commission (TJC) issued a list of abbreviations, acronyms, and symbols that should not be used.
Refer to Table 36-3 Common Medical Abbreviations and Table 36-4 TJC “Do Not Use” Abbreviations, Acronyms, and Symbols.
ROM

44. Apply Your Knowledge NICE JOB! Matching: ANSWER:
___ 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
ANSWER:
NICE JOB! C
Problem list
POMR
Clarity
Confidentiality
Subjective data
Plan
Computerized records
SOMR E B F H
Learning Outcome: Use the six Cs for writing an accurate patient history. A D G

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
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
When recording a patient history, you must do more than just fill out the form.
You must review the pieces of information, organize them, determine their importance, and document the facts.
Whenever you write information on the chart, you must consider its completeness and accuracy.

46. 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
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Determine the chief complaint or the main reason for the patient visit then ask appropriate questions to illicit needed information.
Refer to Table 36-5 Example Questions When Using the PQRST Interview Technique.

47. 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
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
When keying information in an electronic record, it is important to correctly type the information into the record.
When using drop down menus, take care to click the box containing the correct information.

48. Progress Notes Guidelines Arrange in reverse chronological order
Initial / sign entries
Patient identification information
Date & time
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
The progress note is used for established patients who are seen for routine visits or follow-ups.
Guidelines to consider when using a progress note include:
Every entry must be initialed and signed by the person making the entry.
Entries most commonly made on progress notes include documentation for prescription refills, follow-up visits, telephone conversations with patients, appointment cancellations or no shows, and referrals and consultation efforts made by the office for the patient.
The patient name must be recorded on every progress note along with any other identifying information such as birth date or chart number.
All entries must be dated and typically include the time.

49. Polypharmacy Document current medications
Encourage patient to maintain a current list of medications
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Patients often see several physicians or specialists.
It is important to remain up to date on all of the patient’s treatments and medications to reduce the likelihood of polypharmacy or unnecessarily repeating medical tests.
It may be helpful to develop a form or card for the patient to use to list his/her medications. Instruct the patient to use the list and to have it updated by the other physicians that he or she sees.

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
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Offices usually have a standard medical history form that includes:
Personal Data – the patient’s name, birth date, and other basic data
Chief Complaint – it should be short and specific and should cover subjective and/or objective data stated by the patient.
History of present illness
When problem started
What patient has done to treat the problem
Refer to Procedure 36-3 Obtaining a Medical History

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
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Past medical history
Include OTC and herbal medications as well as prescription medications.
Be sure to flag patient drug allergies according to office policy.
Family history – use great care and sensitivity when asking questions

52. Health History Form (cont.)
Social and occupational history
Marital status
Occupation
Sexual orientation
Alcohol/drug use
Review of systems – completed by practitioner
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Social and occupational history – patients may feel uncomfortable or may refuse to provide certain information.
Include questions concerning the patient’s
Level of stress
Exposure to hazardous substances
Heavy lifting
Refer to CONNECT to see a video about Obtaining a Medical History .

53. Apply Your Knowledge Very Good!
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.
Learning Outcome: 36.4 Carry out a patient history using critical thinking skills.
Refer to CONNECT to see exercises about Building the Medical Face Sheet, Printing the Face Sheet, Documenting a Physical Exam , and Documenting a Procedure
Refer to OLC to practice in a live EHR program
Very Good!

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.

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

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