Chapter 36

list steps in order that will help a medical assistant conduct a successful patient interview

1 do the research 2 plan the interview 3 approach the patient and request the interview 4 make the patient feel at ease

steps in order for obtaining a medical history

1 wash hands 2 assemble necessary supplies 3 identify patient, invite to private room 4 explain medical history form 5 ask appropriate questions 6 accurately document responses

which method is used more extensively by large clinics, which may have more than 1 physician who may see the same patient?

POMR

the computerized medical records method uses a combination of

SOMR and POMR

physical or psychological dependence on a substance

addiction

which of the following types of patient information go on a registration form

address, insurance, and marital status

the patient registration form carries the date of the patient's current visit and generally lists the patient's

age, education, and ethnicity

signs and symptoms of amphetamine use include

altered mental status, insomnia, and confusion to paranoia

effective methods of collecting patient data include

asking open-ended questions, asking hypothetical questions, and focusing on the patient

the medical assistant should review the patient's medical record

before the interview

agreeing or disagreeing with a patient can

block further communication

which of the following are examples of nonverbal communication

body language, tone of voice, and facial expression

your communication skills have a direct impact on your

career

which of the following are icebreakers

commenting on the weather, acknowledging the patient's reason for the visit, and introducing yourself

which of the following is essential to protect a patient's privacy

confidentiality

asking open-ended questions during interviews allows patients to

explain the situation in their own words and provide more information that does asking closed-ended questions

the reasons a victim stays in an abusive relationship include

fear of the abuser, isolation, and financial dependence

the patient interview is the _____ in the exam process

first step

entries more commonly made on progress notes include documentation for which of the following

follow up visits, no shows, and prescription refills

patient history provides information for

insurance claims, reportable diseases, and research

during a patient interview it is important to document the medications that the patient

is currently taking

the database of a POMR includes the patients

lab results, medical history NOT diagnostic plan or insurance

the information contained in a chart become

legal record

depression in middle age is often triggered by

life events

which of the following skills are needed to conduct a successful patient interview

listening effectively, using a broad knowledge base, and summarizing to form a general picture

which of the following individuals should know that patients have certain responsibilities when seeking medical care

medical assistant

before a patient interview, the medical assistant should review the patient's medical record for

medications, chronic problems, and history

to conduct a successful interview, you must be aware of

nonverbal communication

a patient with mild anxiety may have heightened ability to

observe and make connections

simply sitting back and hearing what the patient says without providing feedback

passive listening

health history forms include

past medical history, personal data, and chief complaints

which of the following are guidelines to consider when using a progress note

patient name must be on every progress note, all entries must be dated, and it must be arranged in reverse chronological order

expecting reasonable continuity of care and being assured of confidentiality are

patient rights

what should you ask the patient for before conducting an interview?

permission

which of the following can make elderly people dependent on a caregiver

physical and mental disabilities

which of the following individuals can make a diagnosis

physician

the patient's medical and health history is the basis for all treatment rendered by the

practitioner

which of the following are components of the PQRST interview technique?

quality or quantity, region or radiation, and provoke or palliative

objection data

readily apparent and measurable information such as test reults

restatement

repeating what the patient says in your own words

informed consent forms verify that the patient has understood the treatment offered and the possible

side effects and outcomes

verbalizing

stating what you believe the patient is suggesting by the patient's response

a chief complaint is a ____ statement

subjective

a medical history usually includes

surgeries, chief complaint, and known allergies NOT medical insurance

subjective data

thoughts, feelings, and perceptions, including the chief complaint

it is important that the medical assistant approach sensitive topics gently so that the patient does not feel

threatened by the questioning

what is the rationale for filing progress notes in chronological order?

to ensure that the most current patient information is reviewed

though not always the reason, clinicians must consider head injuries, burns, and broken bones can be signs a patient is physically abused

true

instead of using the abbreviation A.S. it is now recommended that medical assistants

write out "left ear"

privacy standards of HIPAA include

written authorization for other types of disclosures, privacy notice that much be posted in a clear location in the healthcare facility