Chapter 20 Patient Interview 2 Learning Objectives Define

Chapter 20 Patient Interview

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Learning Objectives § Define and spell key terms § Define the purpose and the key components of the patient interview § List nine interviewing techniques and list the purpose of each § Identify effective strategies for interviewing the talkative patient and the quiet patient 3

Learning Objectives § Differentiate between closed questions, open-ended questions, and directive statements and give an example of each § List five obstacles to effective interviewing and discuss an effective alternative strategy for each 4

Learning Objectives § Describe techniques that may be used to help patients feel more comfortable discussing sensitive information § List at least three examples of ageappropriate interviewing techniques § List the main components of the medical history 5

Learning Objectives § Conduct a patient interview to obtain a medical history § Accurately document the patient’s medical information on a history form § Describe three methods of documentation 6

First Impressions § Medical assistant’s role is to connect patient with physician or provider § Medical assistant checks vital signs § Medical assistant interviews patient to obtain medical history § Use effective communication § Summarize interview when finished 7

Interviewing Techniques § Closed questions § Open-ended questions § Directive statements § Restating § § § Reflecting Redirecting Active listening Silence Summarizing 8

The Talkative Patient § Establish clear guidelines for the interview § Medical assistant may have to redirect patient to specific interview questions § Ask closed questions that require a “yes” or “no” answer § To ensure accuracy of information, restate the information § Redirect patient in kind, assertive manner 9

The Quiet Patient § Quiet or shy, provide little information § Ask open-ended questions that require more than one- or two-word answers § Practice wording questions ahead of time § Use directive statements 10

Obstacles to Effective Interviewing § Medical assistants should refrain from offering medical advice § Do not provide false reassurance § Keep language and vocabulary professional and accurate § Speak in terms the patient can understand, do not use medical jargon § Take care not to imply judgment 11

Discussing Sensitive Topics § Personal information such as sexual activity, use of birth control, number of sexual partners, bowel and bladder function, and menstrual pattern § Provide privacy and patient comfort; allow patient to remain clothed § Assure information will remain confidential § Begin interview with general questions and end with more personal questions 12

Age-Appropriate Communication § Adapt vocabulary and interviewing strategies appropriate to age of patient § Children—sit at eye level to make eye contact § Older children and adolescents—offer choices whenever possible § Elderly—adapt for any sensory or perceptual deficits 13

The Medical History § Logistical data—DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings § PMH—immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries § FH—information about parents, siblings, and children 14

The Medical History § SH—patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol § ROS—systematic collection of data regarding patient’s overall health 15

Documentation § Patient’s chart is a legal document § Documentation should be thorough, legible, and professional § Do not document in pencil, do not use unapproved abbreviations, do not add late entries, make corrections following facility’s policy guidelines, document facts, and do not make assumptions 16

Types of Documentation § Source-oriented medical record—SOMR § Problem-oriented medical record—POMR § SOAP—subjective, objective, assessment, plan § SOAPE—subjective, objective, assessment, plan, evaluation 17

Subjective Data § Known only by the patient § Patient must share information with the health team § Describe pain, nausea, emotional distress § Include patient’s own words; enclose in quotation marks 18

Objective Data § Obtain through observations by health team § Record data accurately § Use quantitative terms § Include physical examination findings, weight, vital signs, and test results 19

Assessment § Physician’s conclusion about the patient’s condition or diagnosis § Physician may list primary symptoms § May rule out (R/O) certain conditions 20

Plan of Care and Evaluation § Physician describes how patient’s problem will be further evaluated and treated § May include diagnostic studies or treatments § Evaluation describes the patient’s understanding of the overall plan as well as his or her compliance with it 21

Discussion § Differentiate the following subjective and objective findings: § Headache § Ecchymosis § Fever § Diarrhea § Vomiting at home § Vomiting at clinic 22

Credits 23