Chapter 23
The Patient History and Documentation
The Purpose of the Medical History
– Basis for treatment by primary care provider, on-call provider, any provider or specialist
– Helps guide treatment for patient
– Recalls previous treatment
– Review notes and laboratory results
The Purpose of the Medical History
– Base for statistical analysis for:
– Research
– Insurance data
– Health department notices
– Health history and chart notes legal record of patient treatment
Preparing for the Patient
– Make certain:
– Examination room ready
– All supplies available
– You review patient’s chart
Preparing for the Patient
– Bring patient from reception area to where interview will take place
– Speak clearly and plainly
– Make certain patient able to hear you
– Determine if assistance is necessary
Preparing for the Patient
– Friendly greeting appreciated and helpful
– Build rapport with patient
– Use patient’s name often, making certain you pronounce it correctly
– Think globally
Preparing for the Patient
– Introduce yourself and speak plainly
Seat patient comfortably and sit face-to-face to begin
interview>>
Preparing for the Patient
– Please refer to the video library on the Instructor Resources CD to view video “Performing a Professional Patient Assessment."
A Cross-Cultural Model
– Every patient interview is cross-cultural
– Health and illness inseparable from social and cultural beliefs
A Cross-Cultural Model
– Patient’s chief concern: the illness
– Patient’s idea of treatment success: managing illness
– Provider’s chief concern: disease
– Provider’s idea of treatment success: control disease problems
A Cross-Cultural Model
– Questions to ask patients
– What do you think caused your problem?
– When do you think it started?
– What effect does it have on you?
– What are your concerns from this problem?
– What kind of treatment do you expect?
– Respect patient’s perspective
Patient Information Forms
– Demographic data form
– Name and address
– Home, work, cell telephone numbers
– Date of birth
– Social Security number
– Insurance information
– Emergency contact person
– Release of information signature
Patient Information Forms
– Financial information form
– Financial policy of practice
– Billing
– Insurance billing
– Co-payment billing
– Finance charges
Patient Information Forms
– Privacy information form
– Since 2004, HIPAA limited circumstances in which individuals’ PHI can be used or disclosed
– See http://www.hhs.gov/ocr/privacy/ / for details
– Civil penalties for failure to comply
Patient Information Forms
– Release of information form
– Sent to former providers to obtain past medical records
– In some cases can be used to allow sharing of information with family members
Patient Information Forms
– Medical history form
– Present health history, including why patient being seen
– Past health history, personal and family
– Social history including marital status, sexual orientation, occupation
Patient Information Forms
– Medical history form
– Military service dates and assignment
– Body systems review/questionnaire
– Medications currently taken (OTC and prescription)
– Provider’s review of system (ROS)
Computerized Health History
– Patient-generated
– Patient responds on computer to questions and reviews information with MA for completeness
– Provider-generated
– MA completes information on screen during patient interview
The Patient Intake Interview
– Interacting with the patient
– Put patient at ease
– Guide conversation
– Keep on track
– Obtains the most information
– Explain terms or concepts
– Remain professional
– Not be embarrassed or uncomfortable by answers
The Patient Intake Interview
– Please refer to the video library on the Instructor Resources CD to view video “Making Critical Choices.
The Patient Intake Interview
– Interacting with the patient– Update medical history
as needed
– Document chief complaint
The Patient Intake Interview
– Displaying cultural awareness
– Patient who does not speak English
– Patient who is hearing impaired
– If interpreter needed; complete business associate contract (HIPAA)
– Cultural barriers addressed
– Patient with mental disorder
– MA listens and communicates with patient and provider
The Patient Intake Interview
– Being sensitive to patient needs
– Patient may be frightened, hostile, depressed
– Be open to nonverbal and verbal communication
– Maintain professional boundary
– Know when touch is appropriate
The Patient Intake Interview
– Being sensitive to patient needs
– Be patient and understanding
– Calm upset patients
– Uncommunicative patients require special questioning techniques
– Some patients have particular needs
The Patient Intake Interview
– Approaching sensitive topics
– Environment private and free from distractions
– Ask questions in later stages of interview
– Use casual direct eye contact without staring
– Pose questions in matter-of-fact tone
– Adopt nonjudgmental demeanor
– Use “normalize” technique when appropriate
Communication Across the Lifespan
– Patient’s age important in communications
– Infant/child
– Communicate with two patients: parent and child
– Older children
– Child may do better without parent present
– Teenagers
– Old enough to make decision about being seen alone or with parent present
Communication Across the Lifespan
– Patient’s age important in communications
– Older adults
– May be accompanied by another adult
– May request individual be present during interview
– Good idea to have HIPAA waiver signed by patient
The Medical Health History
– Personal data from demographic form
– Chief complaint
– Present illness
– Medications
– Allergies
– Other providers or alternative therapy practitioners being seen
The Medical Health History
– Medical history
– Family history
– Social and occupational history
– Review of systems by physician or provider
The Medical Health History
– SOAP/SOAPER– S = Subjective data; patient’s complaint in his or her own
words– O = Objective, observable, measurable findings– A = Assessment, probable diagnosis based on subjective
and objective factors – P = Plan for treatment, medications, instructions, return
visit information– E = Education for patient– R = Response of patient to education and care given
The Medical Health History
– CHEDDAR – C = Chief complaint, presenting problems,
subjective information– H = History
– Social and physical of presenting problem; contributing data
– E = Examination, body systems review– D = Details of problem(s) and complaint(s)– D = Drugs and dosages; list of current
medications, dosages, frequency– A = Assessment; diagnostic evaluation, further
testing, medications– R = Return visit, if applicable
The Medical Health History
– Chief complaint (CC)
– Specific reason that brought patient to see provider
– Noted in as few words as possible; can be direct quote from patient
– Subjective complaint: known by patient but cannot be seen or measured by provider
The Medical Health History
– Chief complaint characteristics– Location
– Radiation
– Quality
– Severity
– Associated symptoms
– Aggravating factors
– Alleviating factors
– Setting and timing
The Medical Health History
– History of present illness
– CC expanded to give more information and detail
– Allow patient to describe history in their own words
– CC characteristics helpful
– Often based on prior health problem
– Medications and allergies reviewed
– All medications to be listed
The Medical Health History
– Medical history
– Health problems
– Major illnesses
– Surgeries
– Allergies and medications (updated at least annually)
– Update immunizations for adults
The Medical Health History
– Family history
– Provide clues to patient’s present condition
– Hereditary and familial diseases and disorders
– Present ages of siblings, parents, grandparents
– Causes of their death and age at time of death
– Be sensitive to cultural variances
The Medical Health History
– Social history
– Spouse/partner status
– Sexual habits
– Occupation
– Hobbies
– Use of alcohol, tobacco, recreational drugs or other chemical substances
The Medical Health History
– Social history
– Lifestyles/behaviors that put patient at risk
– May be necessary to inquire about home environment
– Poor hygiene
– Frequent infections
– Smoke inhalation
– Burns
– Malnutrition
– Falls (especially in older adults)
The Medical Health History
– Review of systems (ROS)
– Performed during physical examination
– Orderly and systematic check of each part of body
– Elicits information essential to diagnosis of disease
– Both positive and negative findings documented
– Helps to determine clinical diagnosis
Patient’s Record and Its Importance
– Confidential information
– Foundation for planning patient care
– Basis for communication among caregivers
– Statistical analysis in research
– Reporting infectious diseases to health department
– Legal document
Patient’s Record and Its Importance
– HIPAA compliance
– Paper record storage and computer/server areas
– Fax machines
– Workstations
Patient’s Record and Its Importance
– Contents of medical records
– Informed consent forms
– Physical examination outcomes
– Laboratory and diagnostic test results
– Diagnosis and plan of treatment
Patient’s Record and Its Importance
– Contents of medical records
– Surgical reports
– Progress reports
– Follow-up care
– Telephone calls related to care
Patient’s Record and Its Importance
– Contents of medical records
– Discharge summary
– Other communications (providers, laboratories, agencies)
– Patient’s records from other providers
– Medication history
Patient’s Record and Its Importance
– Continuity of Care record (CCR)
– Developed by a number of medical groups
– Makes it easier and more efficient to transport patient medical information between providers
– Improves continuity of care and reduces errors
Patient’s Record and Its Importance
– Continuity of Care record (CCR)
– Patient and provider information
– Insurance data
– Patient’s health status
– Recent care given
– Recommendations for future care
– Reason for referral or transfer
Patient’s Record and Its Importance
– Continuity of Care record (CCR)
– Likely includes advanced directives
– Completed by providers, nurses, medical assistants, ancillary personnel
– Can include outpatient, community-based, inpatient services
– Can be transferred electronically
Methods of Charting/Documentation
– Source-oriented medical records (SOMR)
– Chronological set of notes for each visit
– May be typed by medical transcriptionist from provider’s dictation
Methods of Charting/Documentation
– Problem-oriented medical records (POMR)
– Database: medical history, results from laboratory and diagnostic tests, and physical examination (core of record)
– Problem list: individually identified with assigned numbers
Methods of Charting/Documentation
– Problem-oriented medical records (POMR)
– Diagnostic/treatment plan: provider’s plan for treating patient
– Progress notes: entered on every problem initially recorded
Electronic Medical Records (EMR)
– Mandated by 2010
– Can be a part of TPMS
– Available 24 hours a day
– Can be accessed from outside location
– Available to more than one person at a time
Electronic Medical Records (EMR)
– Can be a part of TPMS
– Storage not a problem
– Errors are less likely than handwritten data
– Capability of “flagging” information or queries to providers
– Standard rules for charting in both paper medical record and EMR pertinent
Rules of Charting
– Charting required for each medication, treatment/procedure, provider and medical assistant action
– Must be accurate, clear, complete, timely, entered properly
– “If it is not charted, it was not done.”
Rules of Charting
– Abbreviations used in charting
– Used extensively to document information
– Some used as short-hand
– Some used to give exact meaning to finding
– Best not to use abbreviations when charting medications
– Keep abbreviations to minimum
– Use only standard abbreviations
Rules of Charting
– Chart organization
– Chart notes in paper medical record kept in chronologic order (most recent first)
– Kept in orderly fashion
– Information needed easily gleaned by each member of clinic staff