Patient Interview and Medical Records

what is a diagnosis

the cause, nature, or manifestations of a condition or problem

what is involved when diagnosing a patient

information gathering, interpretation and judgement, underlying causes

what does an assessment include

gathering a collection of data about an individual’s health state to help a doctor in obtaining a diagnosis for the patient

what is a chief complaint

patient’s own words for the reason they are seeking medical care, listed in chronological order of their appearance and severity

what is an example of a chief complaint

“I have been experiencing ear pain since last week"“

How many years is a patient called new and is required to complete History and demographic forms?

3 years

what are some interview dos

good communication, introduction to patient, have empathy, listen, be observant, open and direct questions

what are some interview don’ts

talk too much, false assurances, give advice, use professional terms, ask judgmental questions

what are the components of a patient’s medical history (know the abbreviation)

database/demographics, PH, FH, SH, ROS

PH

past history

PMH

past medical history

FH

family history

SH

social history

SR

system review

ROS

review of systems

what are the three methods of organizing charts

POMR, SOMR, CMR

POMR

Problem-Oriented Medical Record

SOMR

Source-Orientted Medical Records

CMR

Computerized Medical Records

what is POMR

focuses on solving patient problems, organized by a logical sequence, on computer or handwritten, database-problem list-plan-progress note

what is SOMR

traditional/conventional method, organized by sections that are difficult to track problems, handwritten or transcribed, in chronological order by visit w/ recent note on top

what is CMR

used in multi-practice and HMO, uses paper charts-physician dictates and transcriptionist will transcribe from tapes, no paper- all computer

HMO

Health Maintenance Organization

SOAPE

Subjective, Objective, Assessment, Plans, Evaluation

in SOAPE, S is

the purpose of the visit or chief complaint

in SOAPE, O is

anything that is observed or measurable or vital signs

in SOAPE, A is

the physician’s preliminary diagnosis

in SOAPE, P is

how the health problem will be managed

in SOAPE, E is

the assessment of the patient’s understanding of the treatment and ability to follow treatment plan and diagnostics order

How do you correct an error in the medical chart

draw one line thru, write correction, write initials and the date

how do you sign off in the medical chart

signature your first initial and last name, credentials, your first initial and last name printed, the month/date/year

what are some charting dos

black ink, write legible and spell correctly, sign and date all entries, correct med term

what are some charting don’ts

chart in pencil, obliterate errors, make up new abbreviations or symbols not approved by the facility, chart subjective assumptions or opinions

what are the three interview techniques

closed question, open-ended question, directive statement

what are some examples of closed questioning

do you have pain, how are you today, would you mind telling me about your health history

what are some examples of open-ended questioning

what brings you here today, why don’t you describe your pain, why are you here today

what are some examples of directive statements

tell me about your current problem. describe the pain you are having, tell me how you’ve been feeling

what is the pain scale

a standardized scale in attempt to clarify pain measurements for both physicians and patients

what would your prompt be when asking a patient about their pain

“on a scale of 0-10, 0 being no pain at all to 10 being worst pain in your life, how would you describe your pain?”

what is screening

the process of obtaining information from patients to determine who will be the most beneficial to handle their needs

what is triage

sorting and assessing injuries in trauma/disaster situations with color coded tags from most to least urgent

why is communication important during the screening process?

each patient has different needs, you must communicate efficiently and effectively for them

what challenged might patients face during screening

some patients may be shy or embarrassed, which can prevent them from asking or answering direct questions

how can healthcare professionals better understand patients in these situations

using excellent listening skills to pick up on what the patient is really trying to convey

what should be done before explaining information to a patient?

be familiar with the patient’s background and information first

why is knowing patient information beforehand important?

it helps determine the best way to communicate with each individual

what knowledge base is important when performing patient screening

strong foundation in medical terminology, anatomy and physiology, diseases and disorders, emergency procedures, and medications

why is a strong knowledge base necessary

you will be discussing a variety of conditions and illnesses with patients of all ages and backgrounds so it ensures accurate communication

what should you never assume during patient screening

a patient already understands the information being shared

why might a patient say they understand when they don’t

to avoid feeling embarrassed

how can you confirm that a patient truly understands the information

reflection (paraphrase and restate patients feelings and word), restatement (briefly repeating the exact information provided), clarification (stating back the essential meaning as you understood it)

what is in person screening

the first step between the patient and medical assistant to make the office visit beneficial

where is in-person screening typically conducted

in a private area designated or screening or the privacy of the exam room

why is privacy important during screening

all information obtained is subject to legal and ethical considerations, must remain confidential, and is protected by the Patient Bill of Rights

what is the goal of in-person screening

determine why the patient is seeking health care, their main problem, any additional concerns, and what actions (if any) they have taken

what does the screening process help the patient do

focus on their chief complaint (CC) and its related symptoms, while also identifying other possible health issues

T or F: other concerns besides the chief complaint can be recorded

true

does every patient require the same amount of questioning

no (routine physical=general health, specific complaint=detailed questions, follow up= changes since last visit)

why is establishing an accurate database important

it begins the patient’s medical record and provides crucial information for the physician

what must you do to comply with HIPAA privacy standards

get the patient’s approval before involving another person in the discussion of their private health information and document the permission

how should a medical assistant approach patients during the first contact

not appear rushed or routine but professional, reassuring, and aware that the patient may be nervous or uneasy

why is the first interview with a new patient important

it establishes a favorable relationship between the patient, the medical assistant, and the practice

how should medical assistants handle their own biases

treat all patients with respect and avoid judging based on race, religion, sexual orientation, cultural/ethnic origin, or socioeconomic/educational status

how can you create a non-threatening, relaxed atmosphere

greet the patient by name, state your own name, explain your role and what you would like to do, politely ask for the patient’s cooperation

what nonverbal behaviors should medical assistants be aware of

maintain attentiveness and eye contact to show interest and avoid being overly focused on note taking or the clock

how can you ensure the patient understands what you are saying

speak simply, watch their expressions, repeat if needed, and use a translator or interpreter when necessary

who should do most of the talking during the interview

the patient, since the goal is to learn about their condition and concerns

what does it mean to listen attentively

asking clarifying questions and restating what you think the patient said to confirm understanding

how does nonverbal communication play a role in interviews

patient’s body language may confirm or conflict with their words

why are open-ended questions important

they encourage detailed responses and more useful information than yes/no questions

how should you keep the interview focused

avoid letting the conversation go off course

how do you conclude the screening portion of the interview

summarize the patient’s chief complaint (CC) and additional concerns in decreasing order of importance, confirm with the patient, and record the information

who decides what the medical assistant does during in-person screening

the employing provider decides. Some want the medical assistant to handle only the chief complaint, while others want all preliminary questioning done by the medical assistant

why do some providers have the medical assistant do all preliminary questioning

so the provider can review the information quickly and then begin their examination

what tools are increasingly used to gather patient information

intake questionnaires are used to collect background information and health history for issues like weight management, depression, wound care, and smoking

does the information collected and the use of questionnaires vary

yes, it depends on the provider’s preferences

what attitude should a medical assistant have toward patients

be open, accepting, and respectful, avoid prejudice and treat all patients equally, regardless of financial status, race, religion, age, or social position

how should medical assistants address patients

use titles (Mr., Ms.) or full names. Avoid pet names or terms of endearment unless the patient allows a first-name basis

why is a positive attitude important in patient care

if patients sense negative feelings from the medical assistant, they may be less likely to follow instructions or pay attention to suggestions

OLDCARTSA

onset, location, duration character, aggravating factors, timing, severity, associated symptoms

what should you do after introducing yourself and creating a comfortable environment

asking what brought the patient to the office today

what aspects should be included when documenting a chief complaint

location, radiation, quality, severity, associated symptoms, aggravating factors, alleviating factors, setting and timing

how should the medical assistant summarize the screening

review the information with the patient to confirm accuracy, then record the CC and related symptoms in the chart or EMR

what is the appropriate distance during the interview

maintain 1.5 to 4 feet between you and the patient for comfort and proper eye contact

what additional information should be obtained

secondary concerns, current medications, allergies

how should the screening be concluded

reconfirm the CC, symptoms, and other concerns with the patient, record the information, set up the room for the provider, dismiss the patient professionally, and notify the provider that the patient is ready

what is a patient’s health history

a comprehensive record of the patient’s and their family’s medical history, including previous illnesses, medications, allergies, surgeries, and other relevant health information

how is the health history form completed

patients may complete it before the visit (mailed or online) or in the office prior to the provider’s examination. Forms can range from short to comprehensive

hen is a health history obtained

when a patient is new to the facility, before extensive care is provided, along with a complete physical exam

what should a medical assistant do when obtaining a health history

assist the patient in completing the form, ask clarifying questions, record responses accurately, and use feedback techniques like reflection, restatement, and clarification

what should be included in the health history

chief complaint, past medical history, medications, allergies, hospitalizations and surgeries, family and social history, immunizations

how should medical assistants handle patients with barriers

assist respectfully and without judgment for language, literacy, cultural, or other barriers

who must sign and date the health history form

both the patient and the person reviewing the form

how is the medical assistant involved in patient education

by providing information about diseases, tests, or procedures, and directing patients to educational materials or resources while staying within their scope of practice

what is the review of systems (ROS)

an orderly check of body systems performed by the provider during the exam

what is prioritizing

deciding which patient or task should be handled first based on urgency or severity

what is questioning

a tool used in both screening and interviewing

what is interviewing

more detailed info gathering after screening

what are the five vital signs

body temp, heart rate, respiration rate, blood pressure, pain