1. 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.

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.”

19. 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: degrees Fahrenheit; the patient vomited 30 ml; BP: 120/78; the patient’s burn measured 2 cm.

20. 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.

21. 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.

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

23. Credits