Lecture Clinical procedures for medical assisting (4/e): Chapter 5 – Booth, Whicker, Wyman

CHAPTER

5

Interviewing the
Patient, Taking a
History, and
Documentation
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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.

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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.

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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
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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!

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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

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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

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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.


5­11

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

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5­12

The Patient Interview (cont.)
Eight steps to a successful interview
1. Do research before the interview
– Review patient records
– Be sure test and lab results are on the chart

1. Plan the interview
– Be organized before starting the interview
– Follow office policy

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5­13

The Patient Interview (cont.)

3. Make the patient feel at ease
– Icebreakers
– Appear relaxed
– Eye contact

4. Ask the patient for permission to conduct
the interview
– Makes the patient feel more comfortable
– Emphasizes the importance of the process

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5­14

The Patient Interview (cont.)
5. Ensure privacy/no interruptions
– Close door
– Do not use “pet” names

5. Be respectful with sensitive topics
– Watch for nonverbal cues
– Watch your own nonverbal cues

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5­15

The Patient Interview (cont.)

7. Do not diagnose or give an opinion
– Refer questions to physician
– Do not go beyond your scope of
practice

8. Formulate a general picture

8 Steps
(cont.)

– Summarize key points
– Ask if patient has questions or needs to
add additional information
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5­16

Methods for Collecting Patient Data
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

Restatement of what the patient said in your own
words; stating what you believe the patient is
saying

Focusing on the patient

Shows the patient you are really listening to what
he is saying; maintain eye contact; be relaxed and
open

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5­17

Methods for Collecting Patient Data (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

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5­18

Methods for Collecting Patient Data (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

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

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5­19

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

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5­20

Correct
!

Apply Your Knowledge
1.

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.

2. 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.”

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5­21

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

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5­22

Anxiety
• 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

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5­23

Depression
• Common symptoms
– Profound sadness
– Fatigue
– 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

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5­24

Abuse
• 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

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5­25

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

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