Patient Interview
Learning Objectives
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Define and spell key terms
Define the purpose and the key components of the patient interview
List nine interviewing techniques and list the purpose of each
Identify effective strategies for interviewing the talkative patient and the
quiet patient
 Differentiate between closed questions, open-ended questions, and
directive statements and give an example of each
 List five obstacles to effective interviewing and discuss an effective
alternative strategy for each
 Describe techniques that may be used to help patients feel more
comfortable discussing sensitive information
 List at least three examples of age-appropriate interviewing techniques
 List the main components of the medical history
 Conduct a patient interview to obtain a medical history
 Accurately document the patient’s medical information on a history form
 Describe three methods of documentation
First Impressions
 Medical assistant’s role is to connect patient with physician or provider
 Medical assistant checks _______________
 Medical ___________________ patient to obtain
_______________________
 Use effective communication
 Summarize interview when finished
Interview Techniques
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___________________________
Open-ended questions
___________________________
Restating
___________________________
 Redirecting
 Active listening
 ___________________________
 Summarizing
The Talkative Patient
 Establish clear guidelines for the interview
 Medical assistant may have to redirect patient to specific interview
questions
 Ask ________________questions that require a “yes” or “no” answer
 To ensure accuracy of information, ____________________________
 Redirect patient in kind, assertive manner
The Quiet Patient
 Quiet or shy, provide little information
 Ask open-ended questions that require more than one- or two-word
answers
 Practice wording questions ahead of time
 Use directive statements
Interview
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Medical assistants should refrain from offering medical advice
Do ____________________________ false reassurance
Keep language and vocabulary professional and accurate
Speak in terms the patient can understand, do not use medical jargon
Take care not to imply judgment
Discussing Sensitive Topics
 Personal information such as sexual activity, use of birth control, number of
sexual partners, bowel and bladder function, and menstrual pattern
 Provide __________________________; allow patient to remain clothed
 Assure information will remain __________________
 Begin interview with general questions and end with more personal
questions
Age Appropriate Communication
 Adapt vocabulary and interviewing strategies appropriate to age of patient
 Children—_________________________________
 Older children and adolescents—offer _______________________
whenever possible
 Elderly—adapt for any sensory or perceptual deficits
The Medical History
 _________________________-—DOB, patient’s name, address, insurance
coverage, initial physical examination findings, laboratory findings
 _________________________—immunizations, allergies, prior surgeries,
past or current diseases or disorders, and traumatic injuries
 ______________________—information about parents, siblings, and
children
The Medical History
 _________________—patient’s occupation, hobbies, lifestyle, education,
activities, sleep habits, sexual activity, diet, exercise, use of tobacco, and
alcohol
 _________________________—systematic collection of data regarding
patient’s overall health
Documentation
 Patient’s chart is a ___________________________
 Documentation should be thorough, legible, and professional
 Do not document in pencil, do not use unapproved abbreviations, do not
add late entries, make corrections following facility’s policy guidelines,
document facts, and do not make assumptions
Types of documentation
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Source-oriented medical record—SOMR
Problem-oriented medical record—POMR
SOAP—subjective, objective, assessment, plan
SOAPE—subjective, objective, assessment, plan, evaluation
Subjective Data
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Known _____________________________
Patient must share information with the health team
Describe ______________________________________
Include patient’s own words; enclose in quotation marks
Objective Data
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Obtain through _____________________________________
Record data accurately
Use quantitative terms
Include physical examination
findings_______________________________________
Assessment
 Physician’s conclusion about the patient’s condition or diagnosis
 Physician may list primary symptoms
 May rule out (R/O) certain conditions
Plan of Care and Evaluation
 Physician describes how patient’s problem will be further evaluated and
treated
 May include diagnostic studies or treatments
 Evaluation describes the patient’s understanding of the overall plan as well
as his or her compliance with it
Discussion
 Differentiate the following subjective and objective findings:
 Headache
 Ecchymosis
 Fever
 Diarrhea
 Vomiting at home
 Vomiting at clinic