Obtaining and Recording Patient Histories

1. Obtaining and Recording Patient Histories Seminar 2: MO-260 Medical Office Applications

2. Topics • History Taking • SAMPLE • Medical Assistant Responsibilities • Patient Responsibilities • Patient Rights • Privacy – HIPAA • Importance of Medical / Health History • The Patient Interview • Interviewing Skills • Patient HISTORY • Chief Complaint • History of Present Illness • Review of Systems • Past, Family and Social History • Progress Notes ProfEDomerchie

3. History Taking • Organized technique to obtain pertinent medical information. • Can obtain information from patient, family or bystanders. • SAMPLE is one acronym that can be used as a History Taking method. ProfEDomerchie

4. SAMPLE • Signs/Symptoms • Signs – things you can see or hear • Symptoms – things the patient reports • Allergies • Environmental and Medical allergies are important • Medic Alert tags are also useful • Medications • Prescription and OTC • Including vitamins, herbal remedies • Birth Control Pills • Illicit Drugs • Always get a list of medications • Home O2 rate is also important • What did you take, when, how much? • Past Pertinent Medical Conditions • Underlying medical problems • Recent visits to hospitals/doctors • Recent medical procedures • Recent accidents/falls/trauma • Last Oral Intake • What, how much, when • Important for trauma patients, diabetics • Events Leading to Injury or Illness

5. Medical Assistant Responsibilities The following are some of the Medical Assistant’s responsibilities when obtaining and recording patient histories: • The medical assistant sets the tone of the patient’s office visit, makes patient feel at ease, must use effective interview skills. • The medical assistant prepares the patient and the patient’s chart before the physician enters the exam room to examine the patient. • Conduct the patient interview and record the necessary medical history before the practitioner’s examination process begins. • Complete a thorough history and provide proper documentation to ensure complete and accurate records. • Help physician diagnose and treat the patient. ProfEDomerchie

6. Patient Responsibilities The patient also has responsibilities for the process of obtaining and recording the patient history. • Complete any patient medical or health questionnaires completely and accurately. • Provide accurate information about past medical conditions. • Participate in health-care decisions. • Provide a copy of their advance directive, if they have one. • Follow physician’s orders for treatment; inform physician if the patient anticipates problems with orders. • Provide necessary information for insurance claims. ProfEDomerchie

7. Patient Rights • Patient medical information is subject to legal and ethical considerations. • Right to HIPAA privacy information of the medical office. • Right to considerate and respectful care. • Right to know the identity of caregivers. • Right to Refuse treatment. • Right to know the costs of care. • Right to have an advance directive. ProfEDomerchie

8. Patient Rights continued… Regarding the HIPAA Privacy Rule, the medical office must: • Provide patient with written notice of practices regarding use and disclosure of health information. • Not use or disclose protected information for any purpose not in the privacy notice. • Obtain written authorization to release patient information. • Post the Privacy notice. ProfEDomerchie

9. Why is the Medical/Health History Important? • The medical and health history provides the basis for all treatment rendered. • The medical and health history of patients provides information for all of the following: • Research • Reportable diseases • Insurance claims ProfEDomerchie

10. PATIENT INTERVIEW The patient interview performed by the medical assistant is the first step in the patient examination process. The following information is obtained or confirmed during the patient interview: • Chief Complaint • General Health Questions • Lifestyle Questions • Changes in health since last doctor’s visit. • Medical and Health History ProfEDomerchie

11. PATIENT INTERVIEW continued… When recording the CC or reason for visit, one questioning technique that can be used is PQRST: • Provoke • Quality of pain • Region where located • Signs and symptoms • Time of onset ProfEDomerchie

12. PATIENT INTERVIEW continued… When Documenting Patient Information, try the Six “C’s” method. • Client words • Clarity • Completeness • Conciseness • Chronological order • Confidential ProfEDomerchie

13. INTERVIEWING SKILLS • Show patients that you are organized and professional. • Plan your patient interviews in advance. • Have a format and structure that you follow for each interview, or • follow office policy on patient interviewing procedures if one exists. ProfEDomerchie

14. INTERVIEWING SKILLS continued… Here are some suggested steps for a Medical Assistant to follow when completing a patient interview: • Complete your research before the interview by reviewing patient records and confirming that any test and lab results are in the chart. • Review the information on any questionnaires the patient completed. • Verify the information the patient completed on any questionnaires. • Ensure privacy by going to a room where there will be no interruptions and close the door. • Make the patient feel at ease by using icebreakers, appearing relaxed and prepared, and making eye contact. • Be respectful with sensitive topics. Watch for nonverbal cues, and be aware of your own nonverbal cues. • Formulate a general picture by summarizing key points with the patient. • Ask if the patient has questions or needs to add additional information. • Do not diagnose or give an opinion. Do not go beyond your scope of practice. Be sure to refer any questions to the physician. ProfEDomerchie

15. Patient HISTORY The HISTORY Component Of An Outpatient Visit Has Four Elements: • Chief Complaint (CC) • History of Present Illness (HPI) • Past, Family and Social History (PFSH) • Review of Systems (ROS) – completed by practitioner. ProfEDomerchie

16. CHIEF COMPLAINT (CC) • A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. A chief complaint is a REQUIRED ELEMENT for outpatient visits. • Examples: • Left knee swollen and sore • Cough and fever • Stomach pain and rectal bleeding • Documentation tip: The Chief Complaint cannot be inferred. • The following are examples of documentation that are not considered Chief Complaints. • Patient here for follow-up visit (for what?) • Patient here for second injection (what condition is being treated?) ProfEDomerchie

17. HISTORY OF PRESENT ILLNESS (HPI) HPI section of a patient questionnaire should provide a chronological description of the development of the patient’s presenting illness or problem from the first sign and/or symptom, or from the previous encounter to the present. • Elements of HPI: • Location • Duration • Timing • Severity • Quality • Context / Circumstance • Modifying Factors • Associated Signs and Symptoms Example HPI: 45-year old female describes: intermittent sharp pain (timing/quality) in left hip (location) after falling from a ladder yesterday (context). Also states left leg has some numbness (associated signs and symptoms). Pain an 8 on 1-10 scale (severity). Ibuprofen has had no effect on pain (modifying factors). ProfEDomerchie

18. REVIEW OF SYSTEMS The ROS is completed by the practitioner. • A review of systems (ROS) is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. Information included in the review of systems is used to identify the patient problem, assist in the arrival at a diagnosis, identify differential diagnoses, and determine the testing necessary to attain a definitive diagnosis. ProfEDomerchie

19. Past, Family and Social History (PFSH) The PFSH consists of a review of three history areas: • Past history includes recording of prior major illnesses and injuries; operations; hospitalizations; current medications; allergies; age-appropriate immunization status; and/or age-appropriate feeding/dietary status. • Appendectomy 2 yrs ago • Taking diabetic medications • Allergic to penicillin • Diabetes • Family history involves the recording of the health status or cause of death of parents, siblings and children; specific diseases related to problems identified in the chief complaint or history of presenting illness and/or system review; and/or diseases of family members that may be hereditary or place the patient at risk. • Positive for COPD • Family history of kidney stones • Father died from diabetic complications • Social history contains marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol and tobacco; level of education; sexual history; or other relevant social factors. • Smokes 1 pack a week • Social drinker 4-5 /week • Construction worker (occupation) • Married (marital status) • No current sexual activity ProfEDomerchie

20. PROGRESS NOTES What are Progress Notes? • They are… • Used for established patients • Guidelines • Reverse chronological order • Entries initialed by author • Types – prescription refills, follow-up visits, telephone calls, appointment cancellations / no-shows, referrals, and consultations • Patient identification information • Date ProfEDomerchie

21. PROGRESS NOTES Documenting Patient Information: Methods of Charting When Documenting Patient Information, try the SOAP method for Charting. • SOAP – documentation in a logical manner • Subjective data – what the patient says. • Objective data – measurable information. • Assessment – diagnosis or impression of problem. • Plan of action – options for treatment, medications, tests, consults, patient education, follow-up. ProfEDomerchie