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36-2

Learning Outcomes
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.

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36-3

Learning Outcomes (cont.)

36.4 State the six Cs for writing an accurate
patient history.
36.5 Document on the patients chart accurately.
36.6 Obtain a patient history.
36.7 Identify parts of the health history form.

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36-4

Introduction

The medical assistant

prepares the patient and
the patients 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 practitioners
examination process

How you conduct yourself during the first few moments with the
patient can make a major difference in the patients attitude.

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36-5

The Patient Interview and History

Patient interview

First step in examination

process
Establish a relationship
with the patient

Chief complaint

Subjective statement by
patient describing the most
significant symptoms or
signs of illness

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36-6

The Patient Interview and History

(cont.)

Initial interview

Communication tool
More than just
completing a form
Information

Medical and health

history

Basis for all

treatment rendered
Information for

Research
General health and
Reportable diseases
lifestyle
Changes in health
Insurance claims
The chart is a legal record of treatment
provided. All
since last visit

information must be documented precisely and accurately!

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The Patient Interview and History

(cont.)

Patient rights

Information is
subject to legal and
ethical
considerations
AHAs Patients Bill
of Rights

Some patient rights

Considerate and
respectful care
Know the identity of
caregivers
Refuse treatment
Know the costs of care
Confidentiality
Have an advance
directive

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The Patient Interview and History

(cont.)

Patient responsibilities

Provide accurate information about past

medical conditions

Participate in health-care decisions

Provide a copy of their advance directive

Follow physicians orders for treatment;

inform physician if the patient anticipates
problems with orders

Provide necessary information for

insurance claims
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36-9

The Patient Interview and History

(cont.)
Privacy HIPAA

Provide patient with written notice of practices

regarding use and disclosure of health information
Facilities may not use or disclose protected
information for any purpose not in the privacy
notice
Written authorization is required to release
information
Privacy notice must be posted
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36-10

The Patient Interview and History

(cont.)

HIPAA

Enforcement began in
2003
Individual health-care
workers can be subject
to fines up to $250,000
and 10 years in jail.

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36-11

The Patient Interview and History:

Interviewing Skills

Practice effective listening

Active listener hear, think about, and respond

Be aware of nonverbal clues and body language

Have a broad knowledge base

Necessary to ask appropriate questions

Summarize to form a general picture

Verify information
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36-12

The Patient Interview and History

(cont.)

Eight steps to a successful interview

1. Do research before the interview

2.

Review patient records

Be sure test and lab results are on the chart

Plan the interview

Be organized before starting the interview

Follow office policy

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36-13

The Patient Interview and History (cont.)

3.

Make the patient feel at ease

4.

Icebreakers
Appear relaxed
Eye contact

8 Steps
(cont.)

Ask the patient for an interview

Makes the patient feel more comfortable

Emphasizes the importance of the process
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36-14

The Patient Interview and History (cont.)

5.

Ensure privacy / no interruptions

6.

Close door
Do not use pet names

Be respectful with sensitive topics

8 Steps
(cont.)

Watch for nonverbal cues

Watch your own nonverbal cues

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36-15

The Patient Interview and History (cont.)

7.

Do not diagnose or give an opinion

Refer questions to physician

Do not go beyond your scope of practice
8 Steps
(cont.)

8.

Formulate a general picture

Summarize key points

Ask if patient has questions or needs to add
additional information
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36-16

The Patient Interview and History (cont.)

Methods of Collecting Patient Data
Effective
Characteristic
Asking open-ended
questions

Requires more than a yes-or-no answer; results in

more relevant data

Asking hypothetical
questions

Enables the determination of the patients

knowledge and whether it is accurate

Mirroring / verbalizing the Restating what the patient said in your own words;
implied
stating what you believe the patient is saying
Focusing on the patient

Shows the patient you are really listening to what

he is saying; maintain eye contact; be relaxed and
open

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36-17

The Patient Interview and History (cont.)

Methods of Collecting Patient Data
Effective
Characteristic
Encouraging the patient to
take the lead

Motivates the patient to discuss or describe the

issue in his own way

Encouraging the patient to

provide additional
information

Conveys sincere interest by continuing to explore

topics in more detail when appropriate

Encouraging the patient to

evaluate situation

Provides an idea of the patients point of view;

allows for determination of patients knowledge
and fears

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36-18

The Patient Interview and History (cont.)

Methods of Collecting Patient Data
Ineffective

Characteristic

Asking closed-ended
questions

Provides little information; allows no explanation

of answers; require yes-or-no answers

Asking leading questions

Suggests a desired response; patient tends to agree

without elaboration

Challenging the patient

Patient may feel you are disagreeing with him; he

may become defensive; blocks communication

Probing

Once patient has finished, probing may make him

defensive

Agreeing / disagreeing with Implies that the patient is either right or

patient
wrong; block to communication
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36-19

Using Critical Thinking Skills

Getting at an underlying
meaning

Encourage verbalization of
concerns
Mirror response
Restate patients comments
Verbalize what you think the
patient is implying

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36-20

Apply Your Knowledge

1.

Correct!

What type of question is the following: How have

you been managing your diabetes?

ANSWER: An open-ended question which will allow the

patient to explain the situation more clearly.
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.
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.
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36-21

Your Role as an Observer

Nonverbal communication

May reveal more than

patients words

Listen attentively and

observe the patient closely

Detect a problem that might

otherwise go unnoted
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36-22

Your Role as an Observer: Anxiety

Common emotional
response

White coat syndrome

Mild anxiety

Severe anxiety

Heightened ability to
observe and make
connections

Difficulty focusing on
details
Feels panicky and
helpless
Lack of focus

Hinders your ability to

get the information and
cooperation needed

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36-23

Your Role as an Observer: Depression

Common symptoms

Occurs in late
adolescence, middle
age, and after
retirement

Profound sadness

Fatigue

Difficulty falling asleep

or getting up in the
Signs of substance
morning

Loss of appetite

Loss of energy

abuse can be mistaken

for depression

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36-24

Your Role as an Observer: Abuse

Physical, emotional, or
psychological

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
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36-25

Your Role as an Observer: Abuse (cont.)

Signs of abuse

Head injuries / skull

fractures
Burns that appear
deliberate
Broken bones
Bruises multiple in
various stages of
healing

Severe dehydration /
underweight
Delayed medical
attention
Hair loss
Drug use
Genital injuries

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36-26

Your Role as an Observer: Abuse

Battered women

Afraid to discuss
injuries
Bring suspicions to
physicians attention
Encourage patient to
seek help
Provide information on
community resources

Abused children

Types

Physical
Emotional
Sexual
Neglected

Must be reported to
authorities
Community resources

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36-27

Your Role as an Observer: Abuse (cont.)

Elder abuse

Disabilities that make an elderly

person dependent can also leave
him defenseless against abuse

Suspicious injuries or signs of

neglect

Report to authorities

Find out if there is an elder abuse

hotline in your area
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36-28

Your Role as an Observer:

Drug and Alcohol Abuse

Serious social problems

Decline in quality of
work or relationships
Erratic behavior
Mood changes
Appetite loss
Tiredness
Blackouts
Tremors

Substance abuse

Use of a substance in an
unapproved medical
manner
Not necessarily an
addiction

Addiction

Physical or
psychological
dependence on a
substance

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36-29

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?

ANSWER: The patients answer is vague and evasive. Since

multiple bruises may be a sign of abuse, you should tell the
physician of your suspicions.

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36-30

Documenting Patient Information:

Six Cs
1.
2.
3.
4.
5.
6.

Client words
Clarity
Completeness
Conciseness
Chronological order
Confidential
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36-31

Documenting Patient Information (cont.)

Contents of patient chart

Registration form
Patient medical history
Test results
Records from other physicians or hospitals
Physicians diagnosis and treatment plan
Operative reports
Informed consents
Discharge summary and correspondences
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36-32

Documenting Patient Information (cont.)

Methods of charting
SOAP documentation in a logical manner

Subjective data what the patient says

Objective data measurable information
Assessment diagnosis or impression of problem
Plan of action options for treatment,
medications, tests, consults, patient education,
follow-up
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36-33

Recording the Patients Medical

History

Includes pertinent information

Patient and patients family

Age, previous illness, surgical history, allergies,
medications history, and family medical history
Questioning technique PQRST

Provoke
Quality of pain
Region where located
Signs and symptoms
Time of onset
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36-34

Recording the Patients Medical

History (cont.)

Progress notes

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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36-35

Recording the Patients Medical

History (cont.)

Polypharmacy

Document current
medications

Prescription
OTC
Herbal

Encourage patient to
maintain
a current list
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36-36

Recording the Patients Medical

History (cont.)

Health history form

Personal data
Chief complaint (CC)

Reason patient made the

appointment
Short and specific

History of present illness

Detailed information about CC

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36-37

Recording the Patients Medical

History (cont.)

Health history form

Past medical history

All health problems

Medication and allergies

Family history

May help determine cause of current medical problem

Ages, medical conditions
Age at death and cause
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36-38

Recording the Patients Medical

History (cont.)

Health history form

Social and occupational history

Marital status
Occupation
Sexual orientation
Alcohol / drug use

Review of systems completed by practitioner

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36-39

Apply 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.

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36-40

In Summary

Medical assistant plays a key role in patients

visit

Sets the tone

Makes patient feel at ease
Uses effective interview skills

Thorough history and proper documentation

Complete and accurate records

Help physician diagnose and treat the patient
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36-41

Wisdom is
to the soul
what health
is to the
body.
~ de Saint-Ral
2009 The McGraw-Hill Companies, Inc. All rights reserved