Bài giảng Medical Assisting - Chapter 36: Interviewing the Patient, Taking a History, and Documentation

ChapterPowerPoint® to accompany Second EditionRamutkowski  Booth  Pugh  Thompson  WhickerCopyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Medical AssistingChapter 361Objectives:36-1 Name the skills necessary to conduct a patient interview.36-2 Explain the procedure for conducting a patient interview.36-3 Recognize the signs of anxiety, depression and physical, mental or substance abuse.36-4 State the six C’s for writing an accurate patient history.Interviewing the Patient, Taking a History, and Documentation 2Objectives (cont.)36-5 Document on the patient’s chart accurately.36-6 Identify parts of the Health History form.Patient Billing and Collections 3Introduction You will prepare 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.4The Patient Interview and History Ask the patient specific pieces of information called data.Chief complaint is subjective statement by patient describing the most significant symptoms or signs of illness.5Medical and Health HistoryBasis for all treatmentProvides information for research, reportable diseases and insurance claims.Becomes a legal record of the treatment renderedMust be complete and accurate to be a good defense in case of legal action. All information regarding the patient should be documented precisely and accurately!6Patients RightsAll data that you obtain are subject to legal and ethical considerations.American Hospital Association’s Patients Bill of Rights written in 1973 and revised in 1992.Each state encourages healthcare workers to be aware of and follow this document.7Patient ResponsibilitiesPatients are responsibility to:Provide information that is accurate about past medical conditionsParticipate in decisionsProvide health care agencies with a copy of their advance directive.8Patient’s Responsibilities (cont.)Patients must:Inform physician if they anticipate problems in following any prescribed treatment.Follow the physician orders for treatment.Provide healthcare agencies with necessary information for insurance claims and work with healthcare facility to make arrangement to pay fees.9HIPAA Provide patient with written notice of their practices regarding use and disclosure of health information.Facilities may not use or disclose protected information for any purpose that is not in the privacy notice.Patient consent is required when information is disclosed.Privacy notice must be posted.10HIPAA (cont.)If this act is not followed, individual health care workers can be subject to fines up to $250,00 and 10 years in jail.11Interviewing SkillsTo conduct an interview you will need:To be effective listenerTo be aware of nonverbal clues and body languageTo use a broad knowledge baseTo summarize to form a general picture12Interviewing SuccessfullyEight steps for interviewing success:Do your research before the patient interviewPlan the interview.Approach the patient and request the interview.Conduct the interview in private.Deal with sensitive topics with respect.Do not diagnose or give diagnostic opinions.Formulate the general picture.13Apply Your KnowledgeWhat type of question is the following,“How have you been managing your diabetes? 14Apply Your Knowledge -AnswerAn open-ended question which will allow the patient to explain the situation more clearly.What type of question is the following,“How have you been managing your diabetes? 15Apply Your Knowledge #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.” 16Apply Your Knowledge #2 -AnswerHow 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.” 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.”17Your Role as an ObserverNonverbal communication Listening attentively and observing the patient closely may help detect a problem that might otherwise go unnoted.18AnxietyCommon emotional response when seeing a physician (white coat syndrome.)Mild anxiety – patient has heightened ability to observe and make connections.Severe anxiety- patient has difficulty focusing on details, feels panicky and virtually helpless. Lack of focus will hinder your ability to get the information and cooperation needed.19DepressionCommon symptoms Profound sadnessFatigueDifficulty in falling asleepLoss of appetiteLoss of energyOccurs in late adolescence, middle age, and after retirement.20Physical and Psychological AbuseSuspect abuse if the patient speaks in a guarded way.Unlikely explanation for an injuryNo history of the injury or history may be suspicious.21Signs of Physical AbuseChild’s failure to thriveSevere dehydration or underweightDelayed medical attentionHair lossDrug useGenital injuries22Abused ElderlyDisabilities that make an elderly person dependent can also leave him defenseless against abuse.May have suspicious injuries or show signs of neglectFind out if there is an elder abuse hot-line in your area.23Drug and Alcohol AbusePatient may behave erratically, have mood changes , suffer loss of appetite and be constantly tired.Patient may have no apparent signs or symptoms at first, but may have bruises and trembling hands.Patient may suffer blackoutsPatient may become secretive and guilty about drinking24Apply 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?25Apply Your Knowledge -AnswerWhile 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?Bruises may be a sign of abuse. You should notify the physician immediately if you suspect any type of abuse. 26The Six C’s of ChartingClient words must be recorded exactly.Clarity is essential when describing the patient’s condition.Completeness is required.Conciseness can save time and space.Chronological order and date all entries.Confidentiality to protect the patient’s privacy. 27Contents of the Patient’s ChartsRegistration FormPatient medical historyTest resultsRecords from other physician or hospitalsPhysician’s diagnosis and treatment planOperative reportsInformed consentsDischarge summary and correspondences 28Charting using SOAPS – Subjective data: thoughts, feelings, and chief complaints of the patientO – Objective data: readily apparent and measurable dataA – Assessment: physician’s diagnosis and impressionP – Plan of action: options for treatment29Recording the Patient’s Medical HistoryIncludes pertinent information about the patient and the patient’s family.Age, previous illness, surgical history, allergies, medications history and family medical history.30Methods of ChartingConventional or Source-Oriented Medical Records (SOMR) – arrange according to who provided the information.Problem – Oriented Medical Record (POMR) more extensively and includes databases, problem list and plans of care.Computerized Medical Records – uses both SOMR & POMR from a computer terminal.31Health History FormPersonal DataChief ComplaintHistory of Present IllnessPast Medical HistoryFamily HistorySocial and Occupational HistoryReview of Systems32Apply Your KnowledgeIn what part of the health history form would you record information about whether a patient smokes, drinks, or uses tobacco?33Apply Your Knowledge -AnswerIn what part of the health history form would you record information about whether a patient smokes, drinks, or uses tobacco?The social and occupational history portion of the health history form.34Summary Medical Assistant Taking a thorough history and using proper documentation methods will allow you to ensure that the patient’s records are complete and accurate. Using interviewing skills effectively will help make the interview productive as well as comfortable for the patient.35End of ChapterEnd of Chapter36