Chapter 36 Patient Interview and History

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

- Do research before the interview -plan the interview -Approach the patient and request the interview -make the patient feel at ease

The abbreviation U, which stands for "unit," can be mistaken to mean

-"4". -"0." -"cubic centimeter"

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

-Challenging the patient -Probing

Which of the following are icebreakers?

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

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

-Insurance -Marital status -Address

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

-It must be arranged in reverse chronological order. -All entries must be dated. -Patient name must be on every progress note.

Which of the following materials are needed to obtain a medical history?

-Medical history form -Pen

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

-Prescription refills -Follow-up visits -No-shows

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

-Quality or Quantity -Region or Radiation -Provoke or Palliative

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

-S.Q. -S.C.

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

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

Subjective data include

-chief complaints. -feelings.

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

-ethnicity -age. -education.

Asking open-ended questions during interviews allows patients to

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

Signs of possible child abuse include

-genital injuries. -failure to thrive. -being underweight.

The reasons a victim stays in an abusive relationship include

-isolation. -financial dependence. -fear of the abuser

Patients have the right to

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

Depression seems to occur most frequently during

-late adolescence. -retirement.

Health history forms include

-personal data. -past medical history. -chief complaints.

When a patient has anxiety, it is important to

-provide privacy. -make eye contact. -give the patient time to respond.

List the steps, in order, in obtaining a medical history.

-wash your hands -assemble necessary supplies, review the medical history form, and plan your interview. -explain the medical history form -ask appropriate, open-ended questions related to the medical history form. Listen actively -Accurately document the patients responses

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

-women -children -the elderly

1.Chief Complaint 2. Mirroring 3. Reflection 4. Clarification

1. Subjective statement made by the patient describing the patient's most significant symptoms or signs of illness 2. Restating in your own words what a person is saying 3. When a thought, an idea, or an opinion is formed as a result of deeper thought. 4. Asking questions that provide an increased understanding of a problem.

1. Restatement 2. Subjective Data 3. Objective Data 4. Verbalizing

1.Repeating what a patient says in your own words back to the patient. 2. information about the patient's condition that includes thoughts, feelings, and perceptions. 3.Information about the patient's condition that is readily apparent or measurable. 4.Stating what you believe the patient is suggesting or implying.

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

6

There are ______ steps to help a medical assistant conduct a successful interview.

8

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

Confidentiality

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 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

What types of questions are ideal when determining a reason for visit during the patient interview?

Open-ended

Which of the following is a good interview technique.

PQRST technique

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

Polypharmacy

What is the rationale for asking children various types of questions?

To allow children to feel that their points of view are important

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

To ensure that the most current patient information is reviewed

Ativan, diazepam, Valium, and candy are

benzodiazepines

Your communication skills have a direct impact on your

career

Alternating euphoria and apprehension and an intense craving for more of the drug are symptoms of abuse of

cocaine

The review of symptoms is completed by the

doctor

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

is currently taking.

Depression in middle age is often triggered by

life events.

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

patient

The first step in the exam process is the

patient interview

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

severe anxiety.

Women who are abused often feel

shame

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

skills

Stating what you believe the patient is suggesting by a response is called

verbalizing