Obtain and Document Patient Information
Summary
TLDRThis script outlines a procedure for healthcare professionals to gather patient information using therapeutic communication techniques. It emphasizes the importance of confidentiality, respectful interaction, and accurate documentation in medical records. The process includes greeting the patient, explaining the purpose, verifying personal details, and documenting medical history, including allergies and family health issues.
Takeaways
- 😀 Greet the patient pleasantly and introduce yourself to establish a comfortable rapport.
- 🔒 Choose a quiet, private area for the interview to protect confidentiality and prevent interruptions.
- 📝 Explain the purpose of collecting information to the patient, such as updating medical records.
- 👤 Record the patient's full name, including middle initial, address, marital status, gender, age, date of birth, and contact information.
- 🏠 Verify the accuracy of the patient's information, especially if it has been previously entered into electronic records.
- 👨👩👧👦 Discuss the patient's family medical history, such as mentioning the father's rheumatoid arthritis, to understand genetic factors.
- 🏥 Use therapeutic communication techniques like restatement, reflection, and clarification to obtain patient information.
- 🤔 Be sensitive to the patient's needs and be aware of personal biases to treat all patients with respect.
- 💉 Document the patient's chief complaint, present illness, past medical history, and family and social history for accurate assessment and diagnosis.
- 🚫 Ensure patient information is shared only with authorized healthcare team members in compliance with HIPAA regulations.
- 💻 Use secure practices such as secure passwords and monitor positioning to safeguard patient information in electronic health records.
Q & A
What are the three therapeutic communication techniques mentioned in the script?
-The three therapeutic communication techniques mentioned in the script are restatement, reflection, and clarification.
Why is it important to choose a quiet, private area for the interview when updating medical records?
-Choosing a quiet, private area for the interview is important to protect confidentiality and prevent interruptions while obtaining patient information.
What is the first step in the process of updating a patient's medical record as described in the script?
-The first step is to greet the patient pleasantly, identify him, introduce yourself, and explain your role.
What information should be verified or recorded during the medical record update process according to the script?
-The information to be verified or recorded includes the patient's full name, middle initial, address, zip code, marital status, gender, age, date of birth, telephone numbers, insurance information, and the name, address, and telephone number of the patient's employer.
How should the medical staff handle a patient's self-history form if it has been mailed to the patient before the visit?
-The medical staff should review the self-history form for completeness and use it to assist in the interview process.
What is the significance of maintaining eye contact during the interview, and when might it not be culturally appropriate?
-Maintaining eye contact is significant for creating a friendly, caring atmosphere and establishing trust. However, it may not be culturally appropriate in certain cultures where prolonged eye contact is considered disrespectful or aggressive.
Why is it important to use restatement, reflection, and clarification when discussing the patient's symptoms or concerns?
-Using restatement, reflection, and clarification helps to ensure that the patient's needs are understood accurately and sensitively, facilitating effective communication and building rapport.
What should be done if a patient mentions a family history of a medical condition, such as the father's rheumatoid arthritis in the script?
-The medical staff should make a note of the family history, such as the father's rheumatoid arthritis, to inform the doctor and consider it in the assessment and diagnosis.
What are some of the body structures that the provider might ask about during the medical history interview?
-The provider might ask about various body structures, including the patient's cardiac health, as part of the medical history interview.
What is the significance of documenting allergies in red ink on every page of the history form in a paper file?
-Documenting allergies in red ink ensures that they are highly visible and cannot be overlooked, which is crucial for patient safety, especially in emergency situations.
What are some of the safeguards mandated by HIPAA to protect patient information?
-Some of the safeguards mandated by HIPAA include using secure passwords, placing shields on computer screens, positioning monitors away from high-traffic areas, and securing all medical records.
Outlines
😀 Patient Information Gathering
This paragraph outlines the process of obtaining patient information using restatement, reflection, and clarification. It emphasizes the importance of putting the patient at ease through pleasant greetings, proper introductions, and explaining the role of the interviewer. The script also covers the need for a quiet, private area for interviews to protect confidentiality. The interviewer is instructed to record the patient's full name, address, marital status, gender, age, date of birth, telephone numbers, insurance information, and the employer's details. If the information is already in the electronic record, it must be verified for accuracy. The patient's chief complaint, present illness, past medical history, family history, and social history are to be documented, which are crucial for the provider's assessment and diagnosis. The interviewer is also advised to be sensitive to the patient's needs, aware of personal biases, and respectful of all patients regardless of their background.
Mindmap
Keywords
💡Restatement
💡Reflection
💡Clarification
💡Confidentiality
💡Medical Record
💡Chief Complaint
💡Present Illness
💡Past Medical History
💡Family History
💡HIPAA
💡Allergies
Highlights
Introduction of therapeutic communication techniques for patient care.
Importance of greeting patients pleasantly and introducing oneself.
Explanation of the role in updating medical records to put the patient at ease.
Need for choosing a quiet, private area for patient interviews to protect confidentiality.
Instructions on verifying the accuracy of patient information in electronic records.
Use of restatement, reflection, and clarification to obtain patient information.
Emphasis on maintaining eye contact in a culturally appropriate manner during interviews.
Guidance on documenting patient's full name, address, marital status, gender, age, and date of birth.
Instructions on recording patient's contact information and employer details.
Advice on reviewing self-history forms for completeness before patient visits.
Importance of using positive non-verbal behavior to create a friendly atmosphere.
Need to be sensitive to patient's needs and aware of personal biases during interviews.
Explanation of the process of documenting the patient's chief complaint and present illness.
Instructions on documenting past medical history, family history, and social history.
Guidance on asking questions about different body structures and documenting responses.
Emphasis on explaining medical terminology to the patient for clarity.
Instructions on documenting allergies and other substances in the correct fields of the patient's EHR.
Advice on using secure methods to protect patient information as mandated by HIPAA.
Importance of thanking the patient and maintaining ethical sharing of patient information.
Transcripts
[Music]
in this procedure
you'll learn to use restatement
reflection and clarification
to obtain patient information and
document patient care
accurately to put the patient at ease
greet him pleasantly
identify him introduce yourself and
explain your role hi mr dixon i'm laura
i'm going to be updating your medical
record today to protect confidentiality
and prevent interruptions choose a quiet
private area for the interview we're
updating our medical records and i just
want to make sure we have all your
information correct
explain why you need the information
complete the history form
by using therapeutic communication
techniques
record the patient's full name including
middle initial
his address including apartment number
and zip code
marital status gender age and date of
birth
telephone numbers home sell and
work insurance information and the name
address and telephone number of the
patient's employer
if any of this information has already
been entered into the electronic record
verify that it's still accurate i have
your full name
as oscar curtis dixon is that correct
that's correct can you tell me your date
of birth
11 16 a self history may have been
mailed to the patient before the visit
if so review it for completeness
speak in a pleasant distinct way
remembering to maintain eye contact
if of course it's culturally appropriate
to do so
and marital status uh married two kids
positive non-verbal behavior creates a
friendly
caring atmosphere okay what brings you
in the office today
well i've got shoulder pain but well the
worst part of it
is it it kind of wants to catch
okay i don't know okay so your left
shoulder hurts and sometimes it catches
be sure to use restatement reflection
and clarification
be sensitive to the patient's needs
throughout the interview process
be aware of your personal biases and
treat all patients with respect
whatever their background still will
definitely take a look at your shoulder
do you have any other symptoms or
concerns well i mean overall i'm
starting to wonder if i'm getting my
dad's arthritis
tell me more about your dad's arthritis
well i don't know much i mean to hear
mom tell it it's
rheumatoid so i mean that's all i know
sure be sure to explain
any medical terminology i'll make a note
here of your father's rheumatoid
arthritis
that way the doctor can be aware of your
family history document the patient's
chief complaint
and present illness his past medical
history
and his family and social history the
provider will need this information
to make an accurate assessment and
diagnosis
i'm going to ask some questions about
some different body structures are you
ready
yeah okay have you ever had any cardiac
problems
what's that cardiac means heart have you
ever had any heart problems
in the correct field of the patient's
ehr enter information about his
allergies to drugs
and any other substances such as latex
or certain foods do you have any
allergies to drugs or any other
substances that you know of
well i'm allergic to bees but i carry an
epipen
that as far as any other allergies none
that i know of
in a paper file record any allergies in
red ink on every page of the history
form
on the front of the file and on each
progress notes page
spell correctly write legibly don't skip
lines
and don't erase or mark out anything
if you need to correct a mistake the ehr
will automatically note the time of the
change
and the name of the user who made it
remember to thank the patient
patient information may be legally and
ethically shared
only with members of the health care
team directly involved in caring for the
patient
safeguards mandated by the health
insurance portability
and accountability act or hipaa include
using secure passwords
placing shields on computer screens that
might otherwise be visible to
unauthorized people
positioning monitors away from high
traffic areas
and securing all medical records
[Music]
you
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