Chapter 23 The Patient History and Documentation Copyright

Preparing for the Patient • Make certain of the following: – Examination room is

Preparing for the Patient Click Here to play the video Copyright © 2010 Delmar,

Preparing for the Patient • Introduce yourself and speak plainly – Determine if any

Preparing for the Patient • Introduce yourself and speak plainly – Seat the patient

Preparing for the Patient • Introduce yourself and speak plainly – Build rapport with

The Purpose of the Medical History • Basis for all treatment rendered by physician

The Purpose of the Medical History • Chart – Gives base for statistical analysis

A Cross-Cultural Model • Every patient interview is cross-cultural • Health and illness are

A Cross-Cultural Model • Patient’s chief concern: the illness • Patient’s idea of treatment

A Cross-Cultural Model • Questions to ask patients – – – What do you

Patient Information Forms • Demographic data form – Name; address; home, work, cell telephone

Patient Information Forms • Financial information form – Financial policy of clinic, billing, insurance,

Patient Information Forms • Privacy information form – Since 2004 any release of patient

Patient Information Forms • Release of information form – Authorizes release of health care

Patient Information Forms • Medical history form – Present health history, including why patient

Patient Information Forms • Medical history form – Military service dates and assignment –

Patient Information Forms • Computerized health history – Patient-generated – Provider-generated Copyright © 2010

The Patient Intake Interview • Interacting with the patient – – Put patient at

The Patient Intake Interview Click Here to play the video Copyright © 2010 Delmar,

The Patient Intake Interview • Interacting with the patient – Remain professional – Update

The Patient Intake Interview • Displaying cultural awareness – Patient who does not speak

The Patient Intake Interview • Be sensitive to patient’s needs – – Patient may

The Patient Intake Interview • Be sensitive to patient’s needs – Be patient and

The Patient Intake Interview • Dealing with sensitive topics – – – Ask questions

Communication Across the Lifespan • Patient’s age is important in communications – Infants •

Communication Across the Lifespan • Patient’s age is important in communications – Older adults

The Medical Health History • Personal data from demographic form • Chief complaint •

The Medical Health History • • Medical history Family history Social and occupational history

SOAP/SOAPER • SOAPER method of charting – S = Subjective data, patient’s complaint in

CHEDDAR • CHEDDAR method of charting – C = Chief complaint, presenting problems, subjective

Chief Complaint (CC) • Noted in as few words as possible; can quote the

Chief Complaint (CC) • Characteristics may include: – – – Severity Associated symptoms Aggravating

Present Illness • Usually reflected in CC • May be expanded using the “a

Medical History • Surgeries • Allergies and medications (reviewed at every visit) • Health

Family History • Familial and hereditary health problems • Age of family members; cause

Social History • • Spouse/partner status Sexual habits Hobbies Use of alcohol, recreational drugs,

Social History • Lifestyles/behaviors that put patient at risk • Home environment assessment questions

Review of Systems (ROS) • Orderly and systemic check of each part of anatomy

Review of Systems (ROS) • Patient’s record and its importance • Contents of the

Patient’s Record and its Importance • • Confidential information Foundation for planning patient care

HIPAA Compliance Focuses on Three Vulnerable Areas • Paper record storage and computer/server areas

Contents of Medical Records • • Informed consent forms Physical examination outcomes Laboratory and

Contents of Medical Records • • Surgical reports Progress reports Follow-up care Telephone calls

Contents of Medical Records • Discharge summary • Other communications from providers, laboratories, etc.

Continuity of Care Record (CCR) • Developed by a number of medical groups •

Continuity of Care Record (CCR) • Includes the following: – – – Patient and

Continuity of Care Record (CCR) • Most likely would include advanced directives • To

Methods of Charting/Documentation • Source-oriented medical records – Chronological set of notes for each

Methods of Charting/Documentation • Problem-oriented medical records – Database: history and examination results (core

EMRs • Mandated by 2010 • Can be a part of TPMS – Available

EMRs • Can be a part of TPMS – Storage is simple – Fewer

Rules of Charting • Charting required for every patient contact related to care –

Rules of Charting • Chart organization – – – Must be kept in orderly,

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Preparing for the Patient • Make certain of the following: – Examination room is ready – All supplies are available – You are familiar with the patient’s chart • Bring the patient from the reception area to where the interview will take place Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Preparing for the Patient • Introduce yourself and speak plainly – Determine if any assistance is needed for the patient – If necessary, offer assistance with your friendly greeting – Accompany patient to the examination room and close the door Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Preparing for the Patient • Introduce yourself and speak plainly – Seat the patient comfortably and sit face-to-face to begin the interview Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Preparing for the Patient • Introduce yourself and speak plainly – Build rapport with the patient – Use the patient’s name often, making certain you pronounce it correctly – Think globally as the interview begins Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Purpose of the Medical History • Basis for all treatment rendered by physician or any other provider • Helps to guide treatment for patient Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Purpose of the Medical History • Chart – Gives base for statistical analysis – Serves as a legal record – Should include everything concerning patient treatment Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

A Cross-Cultural Model • Patient’s chief concern: the illness • Patient’s idea of treatment success: managing illness • Provider’s chief concern: disease • Provider’s idea of treatment success: control disease problems Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

A Cross-Cultural Model • Questions to ask patients – – – What do you think caused your problem? When do you think it started? What effect does it have on you? What are your concerns from this problem? What kind of treatment do you expect? • Respect patient’s perspective Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Demographic data form – Name; address; home, work, cell telephone numbers; date of birth – Social Security number, insurance data, emergency contact person Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Financial information form – Financial policy of clinic, billing, insurance, finance charges – Minor patients, missed appointments – Patient signs and receives a copy Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Privacy information form – Since 2004 any release of patient PHI must be disclosed – See http: //www. hhs. gov for details – Civil penalties for failure to comply Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Release of information form – Authorizes release of health care information to specific individuals – Must be in writing, signed, and dated Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Medical history form – Present health history, including why patient is being seen – Past health history, personal and family – Social history including marital status, sexual orientation, occupation Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient Information Forms • Medical history form – Military service dates and assignment – Body systems review/questionnaire – Medications currently taken, including over-thecounter, prescription, and herbal – Provider’s review of system (ROS) Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Interacting with the patient – – Put patient at ease Guide conversation Keep on track Explain terms as needed Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Interacting with the patient – Remain professional – Update history as needed – Remain calm and not embarrassed by any of patient’s comments – Note the chief complaint Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Displaying cultural awareness – Patient who does not speak English – Patient who may be deaf – If interpreter is needed; complete business associate contract (HIPAA) – Cultural barriers addressed – Patient may have other special needs – Medical assistant must listen carefully and communicate effectively Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Be sensitive to patient’s needs – – Patient may be frightened, hostile, or depressed Be aware of nonverbal and verbal communication Know when touch is appropriate Respect boundaries Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Be sensitive to patient’s needs – Be patient and understanding – Calm upset patients – Patient may express a particular need Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Patient Intake Interview • Dealing with sensitive topics – – – Ask questions in later stages of interview Use casual direct eye contact without staring Pose questions in matter-of-fact tone Adopt nonjudgmental demeanor Use “normalize” technique when appropriate Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Communication Across the Lifespan • Patient’s age is important in communications – Infants • Communicate with two patients: parent and infant – Older children • Provider may wish to examine alone – Teenagers • Sets the stage for care in adulthood Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Communication Across the Lifespan • Patient’s age is important in communications – Older adults • May be accompanied by another person, either by choice or because of necessity – May have a HIPAA waiver signed by patient when a second person is in attendance Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

The Medical Health History • Personal data from demographic form • Chief complaint • Present illness – Medications – Allergies – Other providers or alternative therapy practitioners being seen Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

SOAP/SOAPER • SOAPER method of charting – S = Subjective data, patient’s complaint in their own words – O = Objective, observable, measurable findings – A = Assessment, probable diagnosis based on subjective and objective factors – P = Plan for treatment, medications, instructions, return visit information – E = Education for the patient – R = Response of patient to education and care given Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

CHEDDAR • CHEDDAR method of charting – C = Chief complaint, presenting problems, subjective information – H = History • Social and physical of presenting problem; contributing data – E = Examination, body systems review – D = Details of problem(s) and complaint(s) – D = Drugs and dosages; list of current medications, dosages, frequency – A = Assessment; diagnostic evaluation, further testing, medications – R = Return visit, if applicable Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chief Complaint (CC) • Noted in as few words as possible; can quote the patient • Subjective data; be specific about cause, time of onset, and complaint • Characteristics may include: – Location – Radiation – Quality Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chief Complaint (CC) • Characteristics may include: – – – Severity Associated symptoms Aggravating factors Alleviating factors Setting and timing Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Present Illness • Usually reflected in CC • May be expanded using the “a through h” classification above • May include other problems experienced, medications, and allergies Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Medical History • Surgeries • Allergies and medications (reviewed at every visit) • Health problems • Major illnesses • Release of information form Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Family History • Familial and hereditary health problems • Age of family members; cause of death and age at the time • Clues to patient’s present condition Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Review of Systems (ROS) • Orderly and systemic check of each part of anatomy • Document positive and negative findings • Used to make differential/clinical diagnosis Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Patient’s Record and its Importance • • Confidential information Foundation for planning patient care Basis for communication among care givers Legal document Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Contents of Medical Records • • Informed consent forms Physical examination outcomes Laboratory and diagnostic test results Diagnosis and plan of treatment Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Contents of Medical Records • Discharge summary • Other communications from providers, laboratories, etc. • Patient’s records from other providers • Medication history Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Continuity of Care Record (CCR) • Developed by a number of medical groups • Makes it easier to transport patient medical information among providers • Improves continuity of care and reduces errors Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Continuity of Care Record (CCR) • Includes the following: – – – Patient and provider information Insurance data Patient’s health status Recent care given Recommendations for future care Reason for referral Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Continuity of Care Record (CCR) • Most likely would include advanced directives • To be completed by physicians and providers, nurses, medical assistants, ancillary providers • Can be transferred electronically Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Methods of Charting/Documentation • Source-oriented medical records – Chronological set of notes for each visit – May be typed by medical transcriptionist from provider’s dictation Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Methods of Charting/Documentation • Problem-oriented medical records – Database: history and examination results (core of record) – Problem List: identified with assigned numbers – Diagnostic/Treatment Plan: documented chronologically for each problem Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

EMRs • Mandated by 2010 • Can be a part of TPMS – Available 24 hours a day – Can be accessed from outside location – Available to more than one person at a time Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

EMRs • Can be a part of TPMS – Storage is simple – Fewer errors than in handwritten data – Software capability of “flagging” queries to providers • Charting rules are similar to those in the paper record Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Rules of Charting • Charting required for every patient contact related to care – Must be accurate, clear, complete, timely, entered properly – “Act not charted” is considered an “act not done” – Abbreviations used in charting kept to a minimum – Medical record must be understandable to any person reading it Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Rules of Charting • Chart organization – – – Must be kept in orderly, predetermined fashion Chronological order Manual record uses both sides of chart for specific data Contents of miscellaneous section Specific order to be understood by each member of the clinic staff Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.