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Chapter 5 - Interviewing the patient, taking a history, and documentation. The objectives of this chapter are: Identify the skills necessary to conduct a patient interview; implement the procedure for conducting a patient interview; detect the signs of anxiety, depression, and physical, mental, or substance abuse. use the six Cs for writing an accurate patient history. | 5 Interviewing the Patient, Taking a History, and Documentation 5- Learning Outcomes 5.1 Identify the skills necessary to conduct a patient interview. 5.2 Implement the procedure for conducting a patient interview. 5.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse. 5.4 Use the six Cs for writing an accurate patient history. 5- Learning Outcomes (cont.) 5.5 Write on the patient’s chart accurately. 5.6 Carry out a patient history. 5.7 Identify parts of the health history form. 5.8 Use critical thinking skills during a patient interview. 5- Introduction The medical assistant prepares the patient and the patient’s chart before the physician enters the exam room to examine the patient Conducting the patient interview and recording the necessary medical history are essential to the practitioner’s examination process How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s | 5 Interviewing the Patient, Taking a History, and Documentation 5- Learning Outcomes 5.1 Identify the skills necessary to conduct a patient interview. 5.2 Implement the procedure for conducting a patient interview. 5.3 Detect the signs of anxiety; depression; and physical, mental, or substance abuse. 5.4 Use the six Cs for writing an accurate patient history. 5- Learning Outcomes (cont.) 5.5 Write on the patient’s chart accurately. 5.6 Carry out a patient history. 5.7 Identify parts of the health history form. 5.8 Use critical thinking skills during a patient interview. 5- Introduction The medical assistant prepares the patient and the patient’s chart before the physician enters the exam room to examine the patient Conducting the patient interview and recording the necessary medical history are essential to the practitioner’s examination process How you conduct yourself during the first few moments with the patient can make a major difference in the patient’s attitude. 5- The Patient Interview and History Patient interview First step in examination process Establish a relationship with the patient Chief complaint Subjective statement by patient describing the most significant symptoms or signs of illness 5- The Patient Interview and History (cont.) Medical and health history Basis for all treatment rendered Information for Research Reportable diseases Insurance claims The chart is a legal record of treatment provided. All information must be documented precisely and accurately! 5- Patient Rights Information is subject to legal and ethical considerations American Hospital Association’s Patient’s Bill of Rights (Patient Care Partnership) Some patient rights Considerate and respectful care Know the identity of caregivers Refuse treatment Know the costs of care Confidentiality Have an advance directive 5- Patient Responsibilities Provide accurate information about past medical conditions Participate in .
