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Chapter 5 - Interviewing the patient, taking a history, and documentation. The objectives of this chapter are: Identify the skills necessary to conduct a patient interview; implement the procedure for conducting a patient interview; detect the signs of anxiety, depression, and physical, mental, or substance abuse. use the six Cs for writing an accurate patient history.
CHAPTER Interviewing the Patient, Taking a History, and Documentation © 2011 The McGraw-Hill Companies, Inc All rights reserved 52 Learning Outcomes 5.1 Identify the skills necessary to conduct a patient interview 5.2 Implement the procedure for conducting a patient interview 5.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse 5.4 Use the six Cs for writing an accurate patient history © 2011 The McGraw-Hill Companies, Inc All rights reserved 53 Learning Outcomes (cont.) 5.5 Write on the patient’s chart accurately 5.6 Carry out a patient history 5.7 Identify parts of the health history form 5.8 Use critical thinking skills during a patient interview © 2011 The McGraw-Hill Companies, Inc All rights reserved 54 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 © 2011 The McGraw-Hill Companies, Inc All rights reserved 55 The Patient Interview and History • Patient interview – 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 © 2011 The McGraw-Hill Companies, Inc All rights reserved 56 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! © 2011 The McGraw-Hill Companies, Inc All rights reserved 57 Patient Rights • Information is subject to legal and ethical considerations • American Hospital Association’s Patient’s Bill of Rights (Patient Care Partnership) • Some patient rights – Considerate and respectful care – Know the identity of caregivers – Refuse treatment – Know the costs of care – Confidentiality – Have an advance directive © 2011 The McGraw-Hill Companies, Inc All rights reserved 58 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 â 2011 The McGraw-Hill Companies, Inc All rights reserved 59 Patient 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 © 2011 The McGraw-Hill Companies, Inc All rights reserved 510 Patient 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 © 2011 The McGraw-Hill Companies, Inc All rights reserved 535 Terminology and Abbreviations • Avoid incorrect use • Refer to – Office/facility policy – TJC “Do Not Use List” © 2011 The McGraw-Hill Companies, Inc All rights reserved 536 Apply Your Knowledge Matching: ANSWER: _ C Precise descriptions A Problem list _ E What the patient says B POMR B Charting based on problems _ C Clarity F Contains options for treatments _ D Confidentiality H Arrangement based on source of information _ E Subjective data A Lists patient conditions _ F Plan D Essential to protect patient privacy _ G Computerized records G Accessibility to records _ H SOMR N I C E J O B ! © 2011 The McGraw-Hill Companies, Inc All rights reserved 537 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 – Must be complete and accurate © 2011 The McGraw-Hill Companies, Inc All rights reserved 538 The Patient’s Medical History (cont.) • Determine chief complaint • Interviewing technique – PQRST – Provoke or palliative – Quality or quantity – Region or Radiation – Severity Scale – Timing © 2011 The McGraw-Hill Companies, Inc All rights reserved 539 Progress Notes • Used for established patients • Guidelines – Reverse chronological order – Entries initialed by author – Types – prescription refills, follow-up visits, telephone calls, appointment cancellations/noshows, referrals, and consultations – Patient identification information – Date © 2011 The McGraw-Hill Companies, Inc All rights reserved 540 Polypharmacy • Document current medications – Prescription – OTC – Herbal • Encourage patient to maintain a current list of medications © 2011 The McGraw-Hill Companies, Inc All rights reserved 541 Health History Form • Personal data • Chief complaint (CC) – Reason patient made the appointment – Short and specific • History of present illness – detailed information about CC © 2011 The McGraw-Hill Companies, Inc All rights reserved 542 Health History Form (cont.) • 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 © 2011 The McGraw-Hill Companies, Inc All rights reserved 543 Health History Form (cont.) • Social and occupational history – Marital status – Occupation – Sexual orientation – Alcohol/drug use • Review of systems – completed by practitioner © 2011 The McGraw-Hill Companies, Inc All rights reserved 544 Apply Your Knowledge In what part of the health history form you record information about whether a patient smokes, drinks, or uses tobacco? ANSWER: The social and occupational history portion of the health history form © 2011 The McGraw-Hill Companies, Inc All rights reserved 545 In Summary 5.1 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 5.2 For a successful interview you must research, plan, and ask permission Also put the patient at ease, interview in a private area, be sensitive, not diagnose, and form a general picture © 2011 The McGraw-Hill Companies, Inc All rights reserved 546 In Summary (cont.) 5.3 Anxiety can range from a heightened ability to observe to a difficulty to focus Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and loss of appetite Abuse can be physical, such as an injury, or psychological, such as neglect 5.4 The six C’s for writing an accurate patient history include: client’s words, clarity, completeness, conciseness, chronological order, and confidentiality © 2011 The McGraw-Hill Companies, Inc All rights reserved 547 In Summary (cont.) 5.5 Accurate documentation requires attention to detail The medical record is a legal document Correct spelling and correct abbreviations are mandatory 5.6 When obtaining a patient history you can use the PQRST interview technique, review the information obtained, determine the importance, and then document the facts accurately © 2011 The McGraw-Hill Companies, Inc All rights reserved 548 In Summary (cont.) 5.7 The health history form includes personal data, chief complaint, history of present illness, past medical history, family history, social and occupational history, and the review of systems 5.8 Critical thinking during the patient interview requires the use of open-ended questions, active listening, clarification, restatement, and reflection © 2011 The McGraw-Hill Companies, Inc All rights reserved 549 End of Chapter Wis m is to the s o ul what he alth is to the bo dy ~ de SaintRéal © 2011 The McGraw-Hill Companies, Inc All rights reserved ... 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... problems – Decline in quality of work or relationships – Erratic behavior – Mood changes – Appetite loss – Tiredness – Blackouts – Tremors • Substance abuse – Use of a substance in an unapproved medical. .. rights reserved 5 31 Method of Charting • SOAP – documentation in a logical manner – Subjective data – what the patient says – Objective data – measurable information – Assessment – diagnosis or