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Learning ObjectivesLearning 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 ObjectivesLearning 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 ObjectivesLearning 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 ObjectivesLearning Objectives
Conduct a patient interview to obtain a medical history
Accurately document the patient’s medical information on a history form
Describe three methods of documentation
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First ImpressionsFirst Impressions
Medical assistant’s 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 TechniquesInterviewing Techniques
Closed questions Open-ended
questions Directive
statements Restating
Reflecting Redirecting Active listening Silence Summarizing
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The Talkative PatientThe 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 PatientThe 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 InterviewingObstacles 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 TopicsDiscussing 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 CommunicationAge-Appropriate Communication
Adapt vocabulary and interviewing strategies appropriate to age of patient
Children—sit at eye level to make eye contact
Older children and adolescents—offer choices whenever possible
Elderly—adapt for any sensory or perceptual deficits
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The Medical HistoryThe Medical History
Logistical data—DOB, patient’s name, address, insurance coverage, initial physical examination findings, laboratory findings
PMH—immunizations, allergies, prior surgeries, past or current diseases or disorders, and traumatic injuries
FH—information about parents, siblings, and children
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The Medical HistoryThe Medical History
SH—patient’s occupation, hobbies, lifestyle, education, activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and alcohol
ROS—systematic collection of data regarding patient’s overall health
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DocumentationDocumentation Patient’s 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 facility’s policy guidelines, document facts, and do not make assumptions
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Types of DocumentationTypes of Documentation
Source-oriented medical record—SOMR Problem-oriented medical record—
POMR SOAP—subjective, objective,
assessment, plan SOAPE—subjective, objective,
assessment, plan, evaluation
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Subjective DataSubjective Data
Known only by the patient Patient must share information with the
health team Describe pain, nausea, emotional
distress Include patient’s own words; enclose in
quotation marks
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Objective DataObjective 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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AssessmentAssessment
Physician’s conclusion about the patient’s condition or diagnosis
Physician may list primary symptoms May rule out (R/O) certain conditions
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Plan of Care and EvaluationPlan of Care and Evaluation
Physician describes how patient’s problem will be further evaluated and treated
May include diagnostic studies or treatments
Evaluation describes the patient’s understanding of the overall plan as well as his or her compliance with it
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Discussion Discussion Differentiate the following subjective
and objective findings: Headache Ecchymosis Fever Diarrhea Vomiting at home Vomiting at clinic