CHAPTER

36
Patient Interview
and History


36-2

Learning Outcomes (cont.)
36.1 Identify the skills necessary to conduct a
patient interview.
36.2 Recognize the signs of anxiety; depression;
and physical, mental, or substance abuse.
36.3 Use the six Cs for writing an accurate patient
history.
36.4 Carry out a patient history using critical
thinking skills


36-3

Introduction
• The medical assistant
– Prepares the patient
and the patient’s chart

– Records the
necessary medical
history

– Conducts a patient
interview
How you conduct yourself during the first few
moments with the patient can make a major
difference in the patient’s attitude.


36-4

The Patient Interview and History
• Patient interview
– First step in examination process
– Establishes a relationship
– Exchange information

• Establish reason for appointment
– Routine check up
– Illness ~ chief complaint


36-5

The Patient Interview and History (cont.)
• Medical and health history
– Basis for all treatment rendered
– Information for
• Research
• Reportable diseases
• Insurance claims


The chart is a legal record of treatment
provided. All information must be
documented precisely and accurately!


Patient Rights, Responsibilities, and
Privacy
• Information is subject to legal and ethical
considerations
• The Patient Care Partnership:
Understanding Expectations, Rights, and
Responsibilities

36-6


Patient Rights, Responsibilities, and
Privacy (cont.)
• Some patient rights
– Considerate and respectful care
– Know the identity of caregivers
– Refuse treatment
– Know the costs of care
– Confidentiality
– Have an advance directive

36-7


Patient Rights, Responsibilities, and

Privacy (cont.)
• Some patient responsibilities:
– Provide accurate information
– Participate in healthcare decisions
– Provide a copy of their advance directive
– Follow physician’s orders
– Provide information for insurance claims

36-8


Patient Rights, Responsibilities, and
Privacy (cont.)
• HIPAA
– Enforcement began in
2003
– Individual health-care
workers can be subject to
fines up to $250,000 and
10 years in jail.

36-9


Patient Rights, Responsibilities, and
Privacy (cont.)
•

HIPAA requires
–


Written notice of privacy practices

– No use or disclosure of protected information
for purposes not in the privacy notice
– Written authorization to release information
– Posting the privacy notice

36-10


36-11

Communicating with Professionalism
• Communication
skills
– Language skills
and body language
– Impact your career
– Think before you
speak or react


36-12

Interviewing Skills
• Practice effective listening
• Be aware of nonverbal clues and body
language
• Have a broad knowledge base

• Summarize to form a general picture


36-13

Interviewing Skills
• Practice effective
listening
– Listen for details
– General view of
situation
– Active listening
• Look at patient
• Pay attention
• Provide feedback restatement

• Be aware of
nonverbal clues
and body language


36-14

Interviewing Skills (cont.)
• Have a broad knowledge
base
• Summarize to form a
general picture
– Consider the importance
information obtained

– Repeat back a summary of
the information


36-15

Interviewing Successfully
1. Do research before the interview
– Review medical record
– Note issues that may impact health
– Be sure appropriate reports are in the record

1. Plan interview – follow office policies


36-16

Interviewing Successfully (cont.)
3. Request the interview
–

Makes the patient feel more comfortable

–

Emphasizes the importance of the process

3. Make the patient feel at ease
–


Icebreakers

–

Sit and appear
relaxed


36-17

Interviewing Successfully (cont.)
5. Ensure privacy/no interruptions
– Private area or close door
– Develop a rapport with the patient

5. Be respectful with sensitive topics
– Watch for nonverbal cues
– Watch your own nonverbal cues


36-18

Interviewing Successfully (cont.)
7. Do not diagnose or give an opinion
– Refer questions to physician
– Remember your scope of practice

8. Formulate a general picture
– Summarize key points
– Ask if patient has questions or needs to

add additional information


36-19

Interviewing Successfully (cont.)
Effective

Characteristic

Asking openended questions

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

Asking
hypothetical
questions

Enables the determination of the
patient’s knowledge and whether it is
accurate

Mirroring /
verbalizing the
implied

Mirroring – restatement of what the
patient said in your own words.
Verbalizing the 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


36-20

Interviewing Successfully (cont.)
Effective

Characteristic

Encouraging the Motivates the patient to discuss or
patient to take the describe the issue in his own way
lead
Encouraging the
patient to provide
additional
information

Conveys sincere interest by continuing
to explore topics in more detail when
appropriate and provides clarification
of an issue

Encouraging the Provides an idea of the patient’s point of

patient to
view; allows for determination of
evaluate situation patient’s knowledge and fears. Uses
reflection to form a thought, idea, or
opinion


36-21

Interviewing Successfully (cont.)
Ineffective

Characteristic

Asking closed-ended Provides little information; allows no
questions
explanation of answers; require yesor-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



36-22

Interviewing Successfully (cont.)
Ineffective

Characteristic

Probing

Once patient has finished, probing
may make him defensive

Agreeing/disagreeing Implies that the patient is either
with patient
“right” or “wrong”; block to
communication


36-23

Apply Your Knowledge

Correct!

1. What are four skills you will need to conduct a
successful interview? ANSWER:
Effective listening
Being aware of nonverbal cues
Having a broad knowledge base

Summarizing to form a general
picture

2. 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.


36-24

Your Role as an Observer
• Nonverbal communication
may reveal more than
patient’s words
• Listen attentively and
observe the patient closely


36-25

Anxiety
• Common emotional
response
• Mild anxiety – heightened focus
• Severe anxiety – difficulty focusing
• Either a heightened focus or a lack of
focus can hinder the interview process