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36. Interviewing the Patient, Taking a History, and Documentation. Learning Outcomes. 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Implement the procedure for conducting a patient interview.

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Interviewing the Patient, Taking a History, and Documentation

learning outcomes
Learning Outcomes

36.1 Identify the skills necessary to conduct a patient interview.

36.2 Implement the procedure for conducting a patient interview.

36.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse.

36.4 Use the six Cs for writing an accurate patient history.

learning outcomes cont
Learning Outcomes (cont.)

36.5 Write on the patient’s chart accurately.

36.6 Carry out a patient history.

36.7 Identify parts of the health history form.

36.8 Use critical thinking skills during a patient interview.  

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.

the patient interview and history
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
the patient interview and history cont
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!

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


Have an advance directive

Patient Rights
patient responsibilities
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
patient privacy
Patient Privacy
    • 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
patient privacy cont
Patient Privacy (cont.)
    • Enforcement began in 2003
    • Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail.
interviewing skills
Interviewing Skills
  • Practice effective listening
    • Be an active listener
    • Hear, think about, and respond
  • Be aware of nonverbal clues and body language
  • Have a broad knowledge base so you can to ask appropriate questions
  • Summarize to form a general picture – verifies information
the patient interview cont
The Patient Interview (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
the patient interview cont1
The Patient Interview (cont.)
  • Make the patient feel at ease
    • Icebreakers
    • Appear relaxed
    • Eye contact
  • Ask the patient for permission to conduct the interview
    • Makes the patient feel more comfortable
    • Emphasizes the importance of the process
the patient interview cont2
The Patient Interview (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
the patient interview cont3
The Patient Interview (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.)

using critical thinking skills
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
apply your knowledge
Apply Your Knowledge


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.”

your role as an observer
Your Role as an Observer
  • Nonverbal communication may reveal more than patient’s words
  • Listen attentively and observe the patient closely
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

Common symptoms

Profound sadness


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

  • 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
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

Abuse (cont.)
abuse cont1
Abuse (cont.)
  • Women, children, and elderly
    • Are more likely to be abused
    • Observe carefully during interview
    • Report suspected abuse to physician or supervisor
    • Have a list of hotline numbers available
drug and alcohol abuse
Serious social problems

Decline in quality of work or relationships

Erratic behavior

Mood changes

Appetite loss




Substance abuse

Use of a substance in an unapproved medical manner

Not necessarily an addiction


Physical or psychological dependence on a substance

Drug and Alcohol Abuse
apply your knowledge1
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 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!

six cs of documenting patient information
Six Cs of Documenting Patient Information
  • Client words
  • Clarity
  • Completeness
  • Conciseness
  • Chronological order
  • Confidential
patient chart
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
method of charting
Method 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
methods for maintaining records
Methods for Maintaining Records
  • Conventional or source-oriented medical records (SOMR) – information arranged by who provided it
methods for maintaining records cont
Methods for Maintaining Records (cont.)
  • Problem-oriented medical records (POMR)
    • Database – medical history, diagnostic and lab reports, exam reports
    • Problem list – problems dated and assigned a number
    • Diagnostic and treatment plan – tests completed and physician’s plan documented
    • Progress notes
      • Note on each recorded problem
      • Entered chronologically
methods for maintaining records cont1
Methods for Maintaining Records (cont.)
  • Computerized medical records
    • Combination of SOMR and POMR
    • Improved accessibility to patient records
terminology and abbreviations
Terminology and Abbreviations
  • Avoid incorrect use
  • Refer to
    • Office/facility policy
    • TJC “Do Not Use List”



H & P



apply your knowledge2
Apply Your Knowledge



___ 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










the patient s medical history
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
the patient s medical history cont
The Patient’s Medical History (cont.)
  • Determine chief complaint
  • Interviewing technique – PQRST
    • Provoke or palliative
    • Quality or quantity
    • Region or Radiation
    • Severity Scale
    • Timing
progress notes
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
  • Document current medications
    • Prescription
    • OTC
    • Herbal
  • Encourage patient to maintain a current list of medications
health history form
Health History Form
  • Personal data
  • Chief complaint (CC)
    • Reason patient made the appointment
    • Short and specific
  • History of present illness – detailed information about CC
health history form cont
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
health history form cont1
Health History Form (cont.)
  • Social and occupational history
    • Marital status
    • Occupation
    • Sexual orientation
    • Alcohol/drug use
  • Review of systems – completed by practitioner
apply your knowledge3
In what part of the health history form do you record information about whether a patient smokes, drinks, or uses tobacco?Apply Your Knowledge

ANSWER: The social and occupational history portion of the health history form.

Very Good!

in summary
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 For a successful interview you must research, plan, and ask permission. Also put the patient at ease, interview in a private area, be sensitive, do not diagnose, and form a general picture.

in summary cont
In Summary (cont.)

36.3 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.

36.4 The six C’s for writing an accurate patient history include: client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.

in summary cont1
In Summary (cont.)

36.5 Accurate documentation requires attention to detail. The medical record is a legal document. Correct spelling and correct abbreviations are mandatory.

36.6 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.

in summary cont2
In Summary (cont.)

36.7 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.

36.8 Critical thinking during the patient interview requires the use of open-ended questions, active listening, clarification, restatement, and reflection.

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