2. 1 PowerPoint ® to accompany Second Edition Ramutkowski  Booth  Pugh  Thompson  Whicker Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Medical Assisting Chapter 36

3. 2 Objectives: 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

4. 3 Objectives (cont.) 36-5 Document on the patient’s chart accurately. 36-6 Identify parts of the Health History form. Patient Billing and Collections

5. 4 Introduction  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.

6. 5 The 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.

7. 6 Medical and Health History  Basis for all treatment  Provides information for research, reportable diseases and insurance claims.  Becomes a legal record of the treatment rendered  Must 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!

8. 7 Patients Rights  All 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.

9. 8 Patient Responsibilities  Patients are responsibility to: Provide information that is accurate about past medical conditions Participate in decisions Provide health care agencies with a copy of their advance directive.

10. 9 Patient’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.

11. 10 HIPAA  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.

12. 11 HIPAA (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.

13. 12 Interviewing Skills To conduct an interview you will need:  To be effective listener  To be aware of nonverbal clues and body language  To use a broad knowledge base  To summarize to form a general picture

14. 13 Interviewing Successfully Eight steps for interviewing success: 1.Do your research before the patient interview 2.Plan the interview. 3.Approach the patient and request the interview. 4.Conduct the interview in private. 5.Deal with sensitive topics with respect. 6.Do not diagnose or give diagnostic opinions. 7.Formulate the general picture.

15. 14 Apply Your Knowledge What type of question is the following, “How have you been managing your diabetes?

16. 15 Answer Apply Your Knowledge - Answer 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?

17. 16 Apply 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.”

18. 17 Answer Apply Your Knowledge #2 - Answer 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.” 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.”

19. 18 Your Role as an Observer  Nonverbal communication  Listening attentively and observing the patient closely may help detect a problem that might otherwise go unnoted.

20. 19 Anxiety  Common 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.

21. 20 Depression  Common symptoms Profound sadness Fatigue Difficulty in falling asleep Loss of appetite Loss of energy  Occurs in late adolescence, middle age, and after retirement.

22. 21 Physical and Psychological Abuse  Suspect abuse if the patient speaks in a guarded way.  Unlikely explanation for an injury  No history of the injury or history may be suspicious.

23. 22 Signs of Physical Abuse  Child’s failure to thrive  Severe dehydration or underweight  Delayed medical attention  Hair loss  Drug use  Genital injuries

24. 23 Abused Elderly  Disabilities that make an elderly person dependent can also leave him defenseless against abuse.  May have suspicious injuries or show signs of neglect  Find out if there is an elder abuse hot-line in your area.

25. 24 Drug and Alcohol Abuse  Patient 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 blackouts  Patient may become secretive and guilty about drinking

26. 25 Apply 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?

27. 26 Answer Apply Your Knowledge - Answer 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? Bruises may be a sign of abuse. You should notify the physician immediately if you suspect any type of abuse.

28. 27 The Six C’s of Charting 1. C lient words must be recorded exactly. 2. C larity is essential when describing the patient’s condition. 3. C ompleteness is required. 4. C onciseness can save time and space. 5. C hronological order and date all entries. 6. C onfidentiality to protect the patient’s privacy.

29. 28 Contents of the Patient’s Charts  Registration Form  Patient medical history  Test results  Records from other physician or hospitals  Physician’s diagnosis and treatment plan  Operative reports  Informed consents  Discharge summary and correspondences

30. 29 Charting using SOAP  S – Subjective data: thoughts, feelings, and chief complaints of the patient  O – Objective data: readily apparent and measurable data  A – Assessment: physician’s diagnosis and impression  P – Plan of action: options for treatment

31. 30 Recording the Patient’s Medical History  Includes pertinent information about the patient and the patient’s family.  Age, previous illness, surgical history, allergies, medications history and family medical history.

32. 31 Methods of Charting  Conventional 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.

33. 32 Health History Form  Personal Data  Chief Complaint  History of Present Illness  Past Medical History  Family History  Social and Occupational History  Review of Systems

34. 33 Apply Your Knowledge In what part of the health history form would you record information about whether a patient smokes, drinks, or uses tobacco?

35. 34 Answer Apply Your Knowledge - Answer In 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.

36. 35 Summary 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.

37. 36 End of Chapter