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
