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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
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.
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.
Conducting the patient interview and recording the necessary medical history are essential to the practitioner’s examination processIntroduction
How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude.
The chart is a legal record of treatment provided. All information must be documented precisely and accurately!
American Hospital Association’s Patient’s Bill of Rights (Patient Care Partnership)
Some patient rights
Considerate and respectful care
Know the identity of caregivers
Know the costs of care
Have an advance directivePatient Rights
Eight steps to a successful interview
8 Steps (cont.)
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.
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.”
Decline in quality of work or relationships
Use of a substance in an unapproved medical manner
Not necessarily an addiction
Physical or psychological dependence on a substanceDrug and Alcohol Abuse
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.
H & P
___ 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
ANSWER: The social and occupational history portion of the health history form.
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.
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.
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.
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.