Patient Interview Chapter 20 The patient interview occurs when the medical assistant has roomed the patient. The medical assistant and the patient are in a private area, both are seated and comfortable, and the medical assistant begins the interview.

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

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

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

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

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 The medical assistant is typically the first person the patient sees when coming into the medical office. The medical assistant plays an important role in connecting the patient with the provider.

Interviewing Techniques Closed questions Open-ended questions Directive statements Restating Reflecting Redirecting Active listening Silence Summarizing Using a variety of interviewing techniques will assist in obtaining the most complete, relevant information possible from the patient.

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 Talkative patients can make the medical assistant’s job interesting and enjoyable. However, talkative patients can present a challenge. The medical assistant has many patients to care for and many duties relating to his or her job. Talkative patients may take too much of the medical assistant’s time.

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 The quiet patient may be shy or withdrawn. One- or two-word sentences do not provide much detail. Use these strategies to increase the quiet patient’s role in the interview.

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 Medical assistants should never offer advice. Answer patient questions in a factual manner. Never imply judgment. Our job as medical assistants is to provide care for patients free of judgment.

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 Sensitive topics can be handled in a delicate manner. Provide privacy and comfort for the patient, and reassure that all information remains confidential. Start with general questions, and ease into more private questions.

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 Medical assistants should speak to their patients in an age-appropriate fashion. Make the patient as comfortable as possible, and speak in a clear, professional tone. Talk to the patient at the patient’s level of understanding.

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 The initial patient interview is usually conducted to obtain a detailed health history. Some physicians may complete this information, but other times the medical assistant will be doing this.

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 The review of systems is usually done in a head-to-toe approach covering all body systems.

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 The patient’s chart serves as a record of the patient’s medical history as well as a place for recording ongoing care.

Types of Documentation Source-oriented medical record—SOMR Problem-oriented medical record—POMR SOAP—subjective, objective, assessment, plan SOAPE—subjective, objective, assessment, plan, evaluation There are several types of documentation commonly used by health care providers.

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 Examples of subjective data include the following : “I have a headache.” “I feel like I am going to vomit.” “I feel like I have a fever.”

Objective Data Obtain through observations by health team Record data accurately Use quantitative terms Include physical examination findings, weight, vital signs, and test results Objective data include the following: temp: 102.4 degrees Fahrenheit; the patient vomited 30 ml; BP: 120/78; the patient’s burn measured 2 cm.

Assessment Physician’s conclusion about the patient’s condition or diagnosis Physician may list primary symptoms May rule out (R/O) certain conditions The assessment is the provider’s diagnosis or suspected diagnosis.

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 The plan of care describes the treatment determined for the patient. Evaluation is the patient’s understanding of the overall plan. Not all SOAP (subjective, objective, assessment, plan) charting includes evaluation.

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

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