Chapter 20
Patient Interview
2
Learning Objectives
 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
3
Learning Objectives
 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
4
Learning Objectives
 Describe techniques that may be used
to help patients feel more comfortable
discussing sensitive information
 List at least three examples of ageappropriate interviewing techniques
 List the main components of the
medical history
5
Learning Objectives
 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
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First Impressions
 Medical assistant’s role is to connect
patient with physician or provider
 Medical assistant checks vital signs
 Medical assistant interviews patient to
obtain medical history
 Use effective communication
 Summarize interview when finished
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Interviewing Techniques
 Closed questions
 Open-ended
questions
 Directive
statements
 Restating





Reflecting
Redirecting
Active listening
Silence
Summarizing
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The Talkative Patient
 Establish clear guidelines for the interview
 Medical assistant may have to redirect
patient to specific interview questions
 Ask closed questions that require a “yes” or
“no” answer
 To ensure accuracy of information, restate
the information
 Redirect patient in kind, assertive manner
9
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
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Obstacles to Effective
Interviewing
 Medical assistants should refrain from
offering medical advice
 Do not provide 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
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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 privacy and patient comfort; allow
patient to remain clothed
 Assure information will remain confidential
 Begin interview with general questions and
end with more personal questions
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Age-Appropriate Communication
 Adapt vocabulary and interviewing
strategies appropriate to age of patient
 Children—sit at eye level to make eye
contact
 Older children and adolescents—offer
choices whenever possible
 Elderly—adapt for any sensory or
perceptual deficits
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The Medical History
 Logistical data—DOB, patient’s name,
address, insurance coverage, initial
physical examination findings,
laboratory findings
 PMH—immunizations, allergies, prior
surgeries, past or current diseases or
disorders, and traumatic injuries
 FH—information about parents, siblings,
and children
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The Medical History
 SH—patient’s occupation, hobbies,
lifestyle, education, activities, sleep
habits, sexual activity, diet, exercise,
use of tobacco, and alcohol
 ROS—systematic collection of data
regarding patient’s overall health
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Documentation
 Patient’s chart is a legal document
 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
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Types of Documentation
 Source-oriented medical record—SOMR
 Problem-oriented medical record—
POMR
 SOAP—subjective, objective,
assessment, plan
 SOAPE—subjective, objective,
assessment, plan, evaluation
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Subjective Data
 Known only by the patient
 Patient must share information with the
health team
 Describe pain, nausea, emotional
distress
 Include patient’s own words; enclose in
quotation marks
18
Objective Data
 Obtain through observations by health
team
 Record data accurately
 Use quantitative terms
 Include physical examination findings,
weight, vital signs, and test results
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Assessment
 Physician’s conclusion about the
patient’s condition or diagnosis
 Physician may list primary symptoms
 May rule out (R/O) certain conditions
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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
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Discussion
 Differentiate the following subjective
and objective findings:
 Headache
 Ecchymosis
 Fever
 Diarrhea
 Vomiting at home
 Vomiting at clinic
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Credits
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