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.

2. Learning Objectives
Define the purpose and the key components of the patient interview
Identify effective strategies for interviewing the talkative patient and the quiet patient

3. 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

4. Learning Objectives
Describe techniques that may be used to help patients feel more comfortable discussing sensitive information
List the main components of the medical history

5. Learning Objectives
Conduct a patient interview to obtain a medical history
Accurately document the patient’s medical information on a history form

6. First Impressions
Medical professional’s role is to connect patient with physician or provider
Includes: checking vital signs and patient interview 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.

7. 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.

8. The Talkative Patient Establish clear guidelines for the interview
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.

9. 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.

10. Obstacles to Effective Interviewing
Any medical provider other than a physician 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.

11. 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.

12. 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.

13. Bell Work 12-6, 2017
When discussing sensitive issues with patients, what should be your number one goal?
If you have a quiet patient, what type of questions should you ask?
What are some strategies to implement when you have a talkative patient?

14. Bell Work Answers Privacy Open-Ended Questions
Redirection, Ask closed questions that require a “yes” or “no” answer

15. Standard
10) Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through:
History and Physical including but not limited to: family, environmental, social, and mental history
Brief Head to Toe Assessment noting normal vs. abnormal findings
Vital Signs Assessment (VS)
Height/weight, BMI /Calculation
Specimen Collection

16. Objectives
Complete a Health History on a patient

17. The Medical History
Logistical data—DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings
PMH (past medical history)—immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries
FH (Family History)—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.

18. The Medical History
SH (Social History)—patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol
ROS (Review of systems) —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.

19. 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.

20. 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
Patient states “I have a terrible headache” and “I feel like I’m going to throw up”
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.”

21. 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.

22. Subjective v. Objective
Patient has a 9/10 pain
Patient’s blood pressure is 120/80
There is a two inch long incision above the patient’s umbilicus
There is purulent discharge coming from the incision
The patient is the sickest in the hospital
The patient has a fever of 102 F

23. Subjective v Objective
Patient feels weak
Patient fainted in the office
Patient Says he hasn’t been eating much lately
Patient thinks his headache is due to his high blood pressure
Patient’s pregnancy test results were negative

24. Subjective: what the patient says
Objective: what you observe.

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

26. Plan of Care and Evaluation
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.

27. Melinda is a 22 year-old patient who has come to the clinic for the first time to establish care. She is quiet and sky and reluctant to disclose personal information. Her current chief complaint is pelvic discomfort and dysuria. You must obtain a complete health history, including information about sexual activity, birth control, menstrual pattern, and current symptoms.
Describe some strategies that might be employed to put this patient at ease and obtain the necessary data

28. Gloria is a 69 year old patient at the doctor’s office for her annual checkup. She is friendly, talkative woman who loves to tell stories and gets easily sidetracked. She has multiple medical complaints and is eager to discuss them all at great length. A complete health history and evaluation of current complaints must be evaluated in a time-effective manner.
Describe strategies that might be used to keep this patient on track.

29. Complete a Health History

30. Standard
12) Relate a therapeutic procedure/treatment to a specific body system. Create a digital or written artifact explaining anatomy involved with the treatment, reason for treatment, health care professionals assisting or performing treatment and patient education, including precautions that should occur prior to the treatment or procedure.

31. Assignment: Worth 50 points
Write a Fact Sheet on a Therapeutic Procedure
Information should include:
Anatomy and Physiology affected
Therapeutic Treatment defined
Reason for treatment and interventions that can be done.
Patient education, including precautions that should occur prior to the treatment or procedure
health care professionals assisting or performing treatment