Chapter 36: Patient Interview and History

If HIPAA is not followed, individual healthcare workers can be subject to fines up to

$250,000.

List the steps that will help a medical assistant conduct a successful patient interview in the correct order.

1. Do research before the interview 2. Plan the interview 3. Approach the patient and request the interview 4. Make the patient feel at ease

According to the Domestic Violence Resource Center, 85% of victims of domestic violence are women, and those ages ______ are at greatest risk.

20 to 24

To help ensure that medical assistants record patient data accurately, they must follow the ______ Cs of charting.

6

Which of the following are icebreakers?

Acknowledging the patient's reason for the visit Commenting about the weather Introducing yourself

Which of the following is a physical or psychological dependence on a substance?

Addiction

Which of the following are examples of nonverbal communication?

Body language Facial expression

Which of the following are ineffective methods of collecting patient data?

Challenging the patient Probing

Which of the following is a statement made by the patient describing the patient's most significant symptoms or signs of illness?

Chief complaint

Which of the following individuals are more likely to be abused?

Children The elderly Women

Which of the following can save time and space when you are recording information?

Conciseness

Which of the following steps will help a medical assistant conduct a successful patient interview?

Deal with sensitive topics with respect Formulate the general picture Make the patient feel at ease

Why is it important to have a well-conducted interview in the exam room?

Establishes a beneficial relationship between you and the patient.

Which of the following can help put patients at ease and create a relaxed atmosphere?

Icebreakers

Which of the following forms verifies that the patient understands the treatment offered and the possible outcomes?

Informed consent

Which of the following types of patient information go on a registration form?

Insurance Marital status Address

Which of the following are sensitive topics for discussion with patients?

Lifestyle behaviors Sexuality

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

Listening effectively Summarizing to form a general picture Using a broad knowledge base

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

Medical assistant

Which of the following can make elderly people dependent on a caregiver?

Mental disabilities Physical disabilities

Which of the following is restating what a patient says in your own words?

Mirroring

Which of the following are readily apparent and measurable findings in the medical chart?

Objective data

Which of the following is a good interview technique.

PQRST technique

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. It must be arranged in reverse chronological order.

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

Permission

Which of the following is a patient's use of multiple medications?

Polypharmacy

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

Prescription refills No-shows Follow-up visits

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

Provoke or Palliative Region or Radiation Quality or Quantity

Which of the following abbreviations can be mistaken as SL for "sublingual," or as "5 every"?

S.C. S.Q.

Which medical form may have a space for patient remarks, followed by a section for the doctor's comments?

SOMR

The computerized medical records method uses a combination of

SOMR. POMR.

Which of the following is the use of a substance, even an over-the-counter drug, in a way that is not medically approved?

Substance abuse

Which of the following are examples of objective data?

Vital signs Test results

Looking at the patient, paying attention, and providing feedback are components of

active listening.

Information regarding a patient's level of stress and exposure to hazardous substances should be asked

as part of the patient's occupational history.

The medical assistant should review the patient's medical record

before the interview.

Signs of possible child abuse include

being underweight. failure to thrive. genital injuries.

Ativan, diazepam, Valium, and candy are

benzodiazepines.

Agreeing or disagreeing with a patient can

block further communication.

Your communication skills have a direct impact on your

career.

A medical history usually includes the patient's

chief complaint surgeries. known allergies.

The reason a patient came to visit the practitioner is called the

chief complaint.

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

chronic problems. medications. history.

Only the physician can make a diagnosis based on the patient's

complaints. symptoms.

Signs and symptoms of amphetamine use include

confusion to paranoia. altered mental status. insomnia.

The review of symptoms is completed by the

doctor.

If you use improper language skills, or appear to have sloppy body language, you may give the patient the perception that you are not

educated. intelligent.

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

education. age. ethnicity

It is important to observe elderly patients for nonverbal signs of problems, such as

grimacing. foul odors. bruising.

During a patient interview, it is important to document the medications that the patient

is currently taking.

The patient medical chart must be complete and accurate to be a good defense in case of

legal action.

The information contained in a chart becomes a(n)

legal record.

Depression in middle age is often triggered by

life events.

Asking a patient for permission to conduct an interview helps the patient feel

like a participant in the patient's medical care. more comfortable.

A patient with mild anxiety may have a heightened ability to

make connections. observe.

To conduct a successful interview, you must be aware of

nonverbal communication.

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

outcomes. side effects.

Patients are responsible for

participation in decision making about their treatment. providing healthcare agencies with a copy of their written advance directives. following the physician's orders for treatment.

Health history forms include

past medical history. chief complaints. personal data.

Expecting reasonable continuity of care and being assured of confidentiality are ______ rights.

patient

The first step in the exam process is the

patient interview.

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

practitioner.

Select all that apply

refuse treatment to the extent permitted by law. know the immediate and long-term costs of treatment choices. receive considerate and respectful care.

The patient history provides information for

research. reportable diseases. insurance claims.

Repeating what the patient says, in your own words, to the patient is called

restatement.

Medical assistants should never go beyond their

scope of practice.

In the elderly, depression is often mistaken for

senility.

A patient who has difficulty focusing on details, feels panicky, and is virtually helpless has

severe anxiety.

To conduct a successful patient interview and obtain history and health information, you need to apply a variety of

skills

Social and occupational history includes

smoking habits. exercise. diet

A chief complaint is a(n) ______ statement.

subjective

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

threatened by the questioning.

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

write out "left ear."

The privacy standards of HIPAA include

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