Y khoa, dược - Interviewing the patient, taking a history, and documentation

Used for established patients Guidelines Reverse chronological order Entries initialed by author Types – prescription refills, follow-up visits, telephone calls, appointment cancellations/no-shows, referrals, and consultations Patient identification information Date

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36Interviewing the Patient, Taking a History, and Documentation36-2Learning Outcomes36.1 Identify the skills necessary to conduct a patient interview.36.2 Implement the procedure for conducting a patient interview.36.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse.36.4 Use the six Cs for writing an accurate patient history. 36-3Learning Outcomes (cont.)36.5 Write on the patient’s chart accurately.36.6 Carry out a patient history.36.7 Identify parts of the health history form. 36.8 Use critical thinking skills during a patient interview.  36-4Introduction The medical assistant prepares the patient and the patient’s chart before the physician enters the exam room to examine the patientConducting 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.36-5The Patient Interview and History Patient interviewFirst step in examination processEstablish a relationship with the patientChief complaint Subjective statement by patient describing the most significant symptoms or signs of illness36-6The 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!36-7Patient RightsInformation is subject to legal and ethical considerationsAmerican Hospital Association’s Patient’s Bill of Rights (Patient Care Partnership)Some patient rightsConsiderate and respectful careKnow the identity of caregiversRefuse treatmentKnow the costs of careConfidentialityHave an advance directive36-8Patient ResponsibilitiesProvide accurate information about past medical conditionsParticipate in health-care decisionsProvide a copy of their advance directiveFollow physician’s orders for treatment; inform physician if the patient anticipates problems with ordersProvide necessary information for insurance claims36-9Patient PrivacyHIPAAProvide patient with written notice of practices regarding use and disclosure of health informationFacilities may not use or disclose protected information for any purpose not in the privacy noticeWritten authorization is required to release information Privacy notice must be posted36-10Patient Privacy (cont.) HIPAA Enforcement began in 2003Individual health-care workers can be subject to fines up to $250,000 and 10 years in jail.36-11Interviewing SkillsPractice effective listening Be an active listener Hear, think about, and respondBe aware of nonverbal clues and body languageHave a broad knowledge base so you can to ask appropriate questionsSummarize to form a general picture – verifies information36-12The Patient Interview (cont.)Eight steps to a successful interviewDo research before the interviewReview patient recordsBe sure test and lab results are on the chartPlan the interviewBe organized before starting the interviewFollow office policy36-13The Patient Interview (cont.)Make the patient feel at easeIcebreakersAppear relaxedEye contactAsk the patient for permission to conduct the interviewMakes the patient feel more comfortableEmphasizes the importance of the process36-14The Patient Interview (cont.)Ensure privacy/no interruptionsClose doorDo not use “pet” namesBe respectful with sensitive topicsWatch for nonverbal cuesWatch your own nonverbal cues36-15The Patient Interview (cont.)Do not diagnose or give an opinionRefer questions to physicianDo not go beyond your scope of practiceFormulate a general pictureSummarize key pointsAsk if patient has questions or needs to add additional information8 Steps (cont.)36-16Methods for Collecting Patient DataEffectiveCharacteristicAsking 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 impliedRestatement of what the patient said in your own words; stating what you believe the patient is sayingFocusing on the patientShows the patient you are really listening to what he is saying; maintain eye contact; be relaxed and open36-17Methods for Collecting Patient Data (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 opinion36-18Methods for Collecting Patient Data (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 communicationProbingOnce patient has finished, probing may make him defensiveAgreeing/disagreeing with patientImplies that the patient is either “right” or “wrong”; block to communication36-19Using Critical Thinking SkillsGetting at an underlying meaningEncourage verbalization of concernsMirror responseRestate patient’s commentsVerbalize what you think the patient is implying36-20Apply 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?” 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.”ANSWER: 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.”Correct!36-21Your Role as an ObserverNonverbal communication may reveal more than patient’s wordsListen attentively and observe the patient closely36-22AnxietyCommon emotional response – white coat syndromeMild anxiety –heightened ability to observe and make connectionsSevere anxietyDifficulty focusing on detailsFeels panicky and helplessLack of focus Hinders your ability to get the information and cooperation needed36-23DepressionCommon symptoms Profound sadnessFatigueDifficulty falling asleep or getting up in the morningLoss of appetiteLoss of energyOccurs in late adolescence, middle age, and after retirementSigns of substance abuse can be mistaken for depression36-24AbusePhysical, emotional, or psychologicalSuspect abuse If the patient speaks in a guarded wayUnlikely explanation for an injuryNo history of the injury, or history may be suspicious36-25Abuse (cont.)Signs of abuseHead injuries/skull fracturesBurns that appear deliberateBroken bonesBruises – multiple in various stages of healingChild’s failure to thriveSevere dehydration/ underweightDelayed medical attentionHair lossDrug useGenital injuries36-26Abuse (cont.)Women, children, and elderlyAre more likely to be abusedObserve carefully during interviewReport suspected abuse to physician or supervisorHave a list of hotline numbers available 36-27Drug and Alcohol AbuseSerious social problemsDecline in quality of work or relationshipsErratic behaviorMood changesAppetite lossTiredness BlackoutsTremorsSubstance abuseUse of a substance in an unapproved medical mannerNot necessarily an addictionAddictionPhysical or psychological dependence on a substance36-28Apply 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!36-29Six Cs of Documenting Patient InformationClient wordsClarity Completeness Conciseness Chronological orderConfidential36-30Patient ChartRegistration formPatient medical historyTest resultsRecords from other physicians or hospitalsPhysician’s diagnosis and treatment planOperative reportsInformed consentsDischarge summary and correspondences 36-31Method of ChartingSOAP – documentation in a logical mannerSubjective data – what the patient saysObjective data – measurable informationAssessment – diagnosis or impression of problemPlan of action – options for treatment, medications, tests, consults, patient education, follow-up36-32Methods for Maintaining RecordsConventional or source-oriented medical records (SOMR) – information arranged by who provided it36-33Methods for Maintaining Records (cont.)Problem-oriented medical records (POMR)Database – medical history, diagnostic and lab reports, exam reports Problem list – problems dated and assigned a numberDiagnostic and treatment plan – tests completed and physician’s plan documentedProgress notes Note on each recorded problemEntered chronologically36-34Methods for Maintaining Records (cont.)Computerized medical recordsCombination of SOMR and POMRImproved accessibility to patient records36-35Terminology and AbbreviationsAvoid incorrect use Refer toOffice/facility policyTJC “Do Not Use List”NKAH & PAbnlROMWNL36-36Apply Your KnowledgeMatching:___ Precise descriptions A. Problem list___ What the patient says B. POMR___ Charting based on problems C. Clarity___ Contains options for treatments D. Confidentiality___ Arrangement based on source of information E. Subjective data___ Lists patient conditions F. Plan___ Essential to protect patient privacy G. Computerized records___ Accessibility to records H. SOMRHGFEDBACANSWER:NICE JOB!36-37The Patient’s Medical HistoryIncludes pertinent information Patient and patient’s familyAge, previous illness, surgical history, allergies, medications history, and family medical historyMust be complete and accurate36-38The Patient’s Medical History (cont.)Determine chief complaintInterviewing technique – PQRST Provoke or palliativeQuality or quantityRegion or RadiationSeverity ScaleTiming36-39Progress NotesUsed for established patientsGuidelinesReverse chronological orderEntries initialed by authorTypes – prescription refills, follow-up visits, telephone calls, appointment cancellations/no-shows, referrals, and consultationsPatient identification informationDate 36-40PolypharmacyDocument current medicationsPrescription OTCHerbalEncourage patient to maintain a current list of medications36-41Health History FormPersonal dataChief complaint (CC)Reason patient made the appointmentShort and specificHistory of present illness – detailed information about CC36-42Health History Form (cont.)Past medical historyAll health problemsMedication and allergies Family historyMay help determine cause of current medical problemAges, medical conditionsAge at death and cause36-43Health History Form (cont.)Social and occupational historyMarital statusOccupationSexual orientationAlcohol/drug use Review of systems – completed by practitioner36-44Apply Your Knowledge In what part of the health history form do you record information about whether a patient smokes, drinks, or uses tobacco?ANSWER: The social and occupational history portion of the health history form.Very Good!36-45In 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 For a successful interview you must research, plan, and ask permission. Also put the patient at ease, interview in a private area, be sensitive, do not diagnose, and form a general picture.36-46In Summary (cont.)36.3 Anxiety can range from a heightened ability to observe to a difficulty to focus. Depression can be demonstrated through severe fatigue, sadness, difficulty sleeping, and loss of appetite. Abuse can be physical, such as an injury, or psychological, such as neglect.36.4 The six C’s for writing an accurate patient history include: client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.36-47In Summary (cont.)36.5 Accurate documentation requires attention to detail. The medical record is a legal document. Correct spelling and correct abbreviations are mandatory.36.6 When obtaining a patient history you can use the PQRST interview technique, review the information obtained, determine the importance, and then document the facts accurately.36-48In Summary (cont.)36.7 The health history form includes personal data, chief complaint, history of present illness, past medical history, family history, social and occupational history, and the review of systems.36.8 Critical thinking during the patient interview requires the use of open-ended questions, active listening, clarification, restatement, and reflection.36-49End of Chapter 36Wisdom is to the soul what health is to the body. ~ de Saint-Réal

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