Patient Interview

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Chapter 20

• Patient Interview

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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

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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

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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

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Learning Objectives

• Conduct a patient interview to obtain a medical
  history
• Accurately document the patients medical
  information on a history form
• Describe three methods of documentation

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First Impressions

• Medical assistants 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

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Interviewing Techniques

• Closed questions
• Open-ended questions
• Directive statements
• Restating

• Reflecting
• Redirecting
• Active listening
• Silence
• Summarizing

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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

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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

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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

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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

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Age-Appropriate Communication

• Adapt vocabulary and interviewing strategies
  appropriate to age of patient
• Childrensit at eye level to make eye contact
• Older children and adolescentsoffer choices
  whenever possible
• Elderlyadapt for any sensory or perceptual
  deficits

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The Medical History

• Logistical dataDOB, patients name, address,
  insurance coverage, initial physical examination
  findings, laboratory findings
• PMHimmunizations, allergies, prior surgeries,
  past or current diseases or disorders, and
  traumatic injuries
• FHinformation about parents, siblings, and
  children

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The Medical History

• SHpatients occupation, hobbies, lifestyle,
  education, activities, sleep habits, sexual
  activity, diet, exercise, use of tobacco, and
  alcohol
• ROSsystematic collection of data regarding
  patients overall health

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Documentation

• Patients 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 facilitys policy
  guidelines, document facts, and do not make
  assumptions

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Types of Documentation

• Source-oriented medical recordSOMR
• Problem-oriented medical recordPOMR
• SOAPsubjective, objective, assessment, plan
• SOAPEsubjective, objective, assessment, plan,
  evaluation

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Subjective Data

• Known only by the patient
• Patient must share information with the health
  team
• Describe pain, nausea, emotional distress
• Include patients own words enclose in quotation
  marks

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Objective Data

• Obtain through observations by health team
• Record data accurately
• Use quantitative terms
• Include physical examination findings, weight,
  vital signs, and test results

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Assessment

• Physicians conclusion about the patients
  condition or diagnosis
• Physician may list primary symptoms
• May rule out (R/O) certain conditions

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Plan of Care and Evaluation

• Physician describes how patients problem will be
  further evaluated and treated
• May include diagnostic studies or treatments
• Evaluation describes the patients understanding
  of the overall plan as well as his or her
  compliance with it

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Discussion

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

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Credits