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Chapter 23 The Patient History and Documentation

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Page 1: CH 23 Power Point

Chapter 23

The Patient History and Documentation

Page 2: CH 23 Power Point

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

Page 3: CH 23 Power Point

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

Page 4: CH 23 Power Point

Preparing for the Patient

– Make certain:

– Examination room ready

– All supplies available

– You review patient’s chart

Page 5: CH 23 Power Point

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

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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

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Preparing for the Patient

– Introduce yourself and speak plainly

Seat patient comfortably and sit face-to-face to begin

interview>>

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Preparing for the Patient

– Please refer to the video library on the Instructor Resources CD to view video “Performing a Professional Patient Assessment."

Page 9: CH 23 Power Point

A Cross-Cultural Model

– Every patient interview is cross-cultural

– Health and illness inseparable from social and cultural beliefs

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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

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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

Page 12: CH 23 Power Point

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

Page 13: CH 23 Power Point

Patient Information Forms

– Financial information form

– Financial policy of practice

– Billing

– Insurance billing

– Co-payment billing

– Finance charges

Page 14: CH 23 Power Point

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

Page 15: CH 23 Power Point

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

Page 16: CH 23 Power Point

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

Page 17: CH 23 Power Point

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)

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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

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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

Page 20: CH 23 Power Point

The Patient Intake Interview

– Please refer to the video library on the Instructor Resources CD to view video “Making Critical Choices.

Page 21: CH 23 Power Point

The Patient Intake Interview

– Interacting with the patient– Update medical history

as needed

– Document chief complaint

Page 22: CH 23 Power Point

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

Page 23: CH 23 Power Point

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

Page 24: CH 23 Power Point

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

Page 25: CH 23 Power Point

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

Page 26: CH 23 Power Point

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

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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

Page 28: CH 23 Power Point

The Medical Health History

– Personal data from demographic form

– Chief complaint

– Present illness

– Medications

– Allergies

– Other providers or alternative therapy practitioners being seen

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The Medical Health History

– Medical history

– Family history

– Social and occupational history

– Review of systems by physician or provider

Page 30: CH 23 Power Point

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

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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

Page 32: CH 23 Power Point

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

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The Medical Health History

– Chief complaint characteristics– Location

– Radiation

– Quality

– Severity

– Associated symptoms

– Aggravating factors

– Alleviating factors

– Setting and timing

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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

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The Medical Health History

– Medical history

– Health problems

– Major illnesses

– Surgeries

– Allergies and medications (updated at least annually)

– Update immunizations for adults

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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

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The Medical Health History

– Social history

– Spouse/partner status

– Sexual habits

– Occupation

– Hobbies

– Use of alcohol, tobacco, recreational drugs or other chemical substances

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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)

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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

Page 40: CH 23 Power Point

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

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Patient’s Record and Its Importance

– HIPAA compliance

– Paper record storage and computer/server areas

– Fax machines

– Workstations

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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

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Patient’s Record and Its Importance

– Contents of medical records

– Surgical reports

– Progress reports

– Follow-up care

– Telephone calls related to care

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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

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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

Page 46: CH 23 Power Point

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

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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

Page 48: CH 23 Power Point

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

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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

Page 50: CH 23 Power Point

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

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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

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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

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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.”

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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

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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