Y khoa - Dược - Chapter 36: Patient interview and history

36Patient Interview and HistoryLearning Outcomes (cont.)36.1 Identify the skills necessary to conduct a patient interview. 36.2 Recognize the signs of anxiety; depression; and physical, mental, or substance abuse. 36.3 Use the six Cs for writing an accurate patient history. 36.4 Carry out a patient history using critical thinking skills Introduction The medical assistantPrepares the patient and the patient’s chartConducts a patient interview Records the necessary medical history How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude.The Patient Interview and History Patient interviewFirst step in examination processEstablishes a relationshipExchange informationEstablish reason for appointmentRoutine check upIllness ~ chief complaintThe Patient Interview and History (cont.)Medical and health historyBasis for all treatment renderedInformation forResearchReportable diseasesInsurance claimsThe chart is a legal record of treatment provided. All information must be documented precisely and accurately!Patient Rights, Responsibilities, and PrivacyInformation is subject to legal and ethical considerationsThe Patient Care Partnership: Understanding Expectations, Rights, and ResponsibilitiesPatient Rights, Responsibilities, and Privacy (cont.)Some patient rightsConsiderate and respectful careKnow the identity of caregiversRefuse treatmentKnow the costs of careConfidentialityHave an advance directivePatient Rights, Responsibilities, and Privacy (cont.)Some patient responsibilities: Provide accurate information Participate in healthcare decisionsProvide a copy of their advance directiveFollow physician’s orders Provide information for insurance claimsPatient Rights, Responsibilities, and Privacy (cont.)HIPAA Enforcement began in 2003Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail.Patient Rights, Responsibilities, and Privacy (cont.)HIPAA requiresWritten notice of privacy practicesNo use or disclosure of protected information for purposes not in the privacy noticeWritten authorization to release information Posting the privacy noticeCommunicating with ProfessionalismCommunication skillsLanguage skills and body languageImpact your careerThink before you speak or reactInterviewing SkillsPractice effective listening Be aware of nonverbal clues and body languageHave a broad knowledge base Summarize to form a general picture Interviewing SkillsPractice effective listening Listen for details General view of situationActive listeningLook at patientPay attentionProvide feedback - restatementBe aware of nonverbal clues and body languageInterviewing Skills (cont.)Have a broad knowledge base Summarize to form a general pictureConsider the importance information obtained Repeat back a summary of the informationInterviewing SuccessfullyDo research before the interviewReview medical recordNote issues that may impact healthBe sure appropriate reports are in the recordPlan interview – follow office policiesInterviewing Successfully (cont.)Request the interviewMakes the patient feel more comfortableEmphasizes the importance of the processMake the patient feel at easeIcebreakersSit and appear relaxedInterviewing Successfully (cont.)Ensure privacy/no interruptionsPrivate area or close doorDevelop a rapport with the patientBe respectful with sensitive topicsWatch for nonverbal cuesWatch your own nonverbal cuesInterviewing Successfully (cont.)Do not diagnose or give an opinionRefer questions to physicianRemember your scope of practiceFormulate a general pictureSummarize key pointsAsk if patient has questions or needs to add additional informationInterviewing Successfully (cont.)EffectiveCharacteristicAsking open-ended questionsRequires more than a yes-or-no answer; results in more relevant dataAsking hypothetical questionsEnables the determination of the patient’s knowledge and whether it is accurateMirroring /verbalizing the impliedMirroring – restatement of what the patient said in your own words. Verbalizing the implied – stating what you believe the patient is sayingFocusing on the patientShows the patient you are really listening to what he is sayingInterviewing Successfully (cont.)EffectiveCharacteristicEncouraging the patient to take the leadMotivates the patient to discuss or describe the issue in his own wayEncouraging the patient to provide additional informationConveys sincere interest by continuing to explore topics in more detail when appropriate and provides clarification of an issueEncouraging the patient to evaluate situationProvides 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 opinionInterviewing Successfully (cont.)IneffectiveCharacteristicAsking closed-ended questionsProvides little information; allows no explanation of answers; require yes-or-no answersAsking leading questionsSuggests a desired response; patient tends to agree without elaborationChallenging the patientPatient may feel you are disagreeing with him; he may become defensive; blocks communicationInterviewing Successfully (cont.)IneffectiveCharacteristicProbingOnce patient has finished, probing may make him defensiveAgreeing/disagreeing with patientImplies that the patient is either “right” or “wrong”; block to communicationApply Your KnowledgeANSWER: An 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?” What are four skills you will need to conduct a successful interview?ANSWER: Effective listeningBeing aware of nonverbal cuesHaving a broad knowledge baseSummarizing to form a general pictureCorrect!Your Role as an ObserverNonverbal communication may reveal more than patient’s wordsListen attentively and observe the patient closelyAnxietyCommon emotional responseMild anxiety – heightened focusSevere anxiety – difficulty focusing Either a heightened focus or a lack of focus can hinder the interview processDepressionClassic symptoms Profound sadnessFatigueAdditional problems Difficulty falling asleep or getting up in the morningLoss of appetiteLoss of energyDepressionIn adolescence Difficult to distinguish from addiction and substance abuseNotify physician if any of these are suspectedMiddle age – triggered by life eventsElderly – mistaken for senilityPhysical and Psychological AbusePhysical, psychological, or bothSuspect abuse If the patient speaks in a guarded wayUnlikely explanation for an injuryPhysical and Psychological Abuse (cont.)Signs of abuseHead injuries/skull fracturesBurns that appear deliberateBroken bonesBruises – multiple; in various stages of healingPhysical and Psychological Abuse (cont.)Other signs of abuseA child’s failure to thrive Severe dehydration or underweight Delayed medical attention Hair loss Drug use Genital injuriesThe Interview and AbuseWomen, children, and elderlyMore likely to be abusedObserve carefully during interviewReport suspected abuse to physician or supervisorHave a list of hotline numbers available The Interview and Abuse (cont.)WomenOften feel shame Listen carefully, be nonjudgmentalChildren Observe for nonverbal cuesWatch relationship between child and caregiverElderly – observe carefullyDrug and Alcohol AbuseSubstance abuse and addictionSymptoms vary with substance abusedCause Decline in work and relationshipsErratic behaviorMood changesLoss of appetiteConstant tiredness Apply Your KnowledgeWhile 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. Good Answer!Documenting Patient InformationClient’s words – record exactlyClarity – use medical terminology and precise descriptionsCompleteness – fill in formsDocumenting Patient Information (cont.)Conciseness Chronological order – date all entriesConfidentiality – protects patient’s privacyContents of Patient ChartsRegistration formPatient medical historyTest resultsRecords from other physicians or hospitalsContents of Patient ChartsPhysician’s diagnosis and treatment planOperative reportsInformed consentsDischarge summary Correspondence Methods of ChartingSOAP Subjective data Objective dataAssessment Plan of action Methods of Charting (cont.)Source-oriented medical records (SOMR) Conventional Information is arranged by who provided itProblem-oriented medical records (POMR)Database ~ foundation of the POMR recordProblem list – each problem is dated and numberedDiagnostic and treatment plan Progress notes – chronological orderMethods of Charting (cont.)Methods of Charting (cont.)Computerized medical recordsCombination of SOMR and POMRImproved accessibility to patient recordsCommon Chart Terminology and AbbreviationsUse only approved abbreviations Refer toOffice/facility policyTJC “Do Not Use List”NKAH & PAbnlROMWNLApply Your KnowledgeMatching:___ Precise descriptions ___ What the patient says ___ Charting based on problems ___ Contains options for treatments ___ Arrangement based on source  of information___ Lists patient conditions ___ Essential to protect patient privacy ___ Accessibility to records HGFEDBACANSWER:NICE JOB!Problem listPOMRClarityConfidentialitySubjective dataPlanComputerized recordsSOMRRecording the Patient’s Medical HistoryIncludes pertinent information About the patient and patient’s family medical historyAge, surgical history, allergies, medications Must be complete and accurateRecording the Patient’s Medical History (cont.)Determine chief complaintInterviewing technique – PQRST Provoke or palliativeQuality or QuantityRegion or RadiationSeverity scaleTimingRecording the Patient’s Medical History (cont.)Key correct information into the EHRPay attention to spellingUse only approved abbreviationsSelect the correct item from menusProgress NotesGuidelinesArrange in reverse chronological orderInitial / sign entriesPatient identification informationDate & timePolypharmacyDocument current medicationsEncourage patient to maintain a current list of medicationsHealth History FormPersonal dataChief complaint (CC)Reason patient made the appointmentShort and specificHistory of present illness – detailed information about CCHealth History Form (cont.)Past medical historyAll health problemsMedicationsAllergies Family historyMay help determine cause of current problemAges, medical conditionsAge at death and causeHealth History Form (cont.)Social and occupational historyMarital statusOccupationSexual orientationAlcohol/drug use Review of systems – completed by practitionerApply Your KnowledgeWhen recording the patient’s chief complaint, you will probably need to ask more questions. What tool can you use to help you ask the appropriate questions?ANSWER: The interviewing technique – PQRST, will help you to remember the types of questions that are appropriate for the problem.Very Good!In Summary36.1 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 Anxiety can range from a heightened ability to observe to a difficulty in being able to focus. Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and lost of appetite. Abuse can be physical or psychological.In Summary (cont.)36.3 The six Cs for writing an accurate patient history include client’s words, clarity, completeness, conciseness, chronological order, and confidentiality. 36.4 When obtaining a patient history, you can use open-ended questions, active listening, clarification, restatement, reflection, and the PQRST interview technique; review the information obtained, determine the importance, and then document the facts accuratelyEnd of Chapter 36Wisdom is to the soul what health is to the body. ~ de Saint-Réal