Health History and Documentation

Question 1

What kinds of things should you do to prepare for an interview with a patient?

Answer 1

1. Do your homework
2. Dress professionally
3. Environment
4. Introduce yourself
5. Ask them the reason for the visit

Question 2

What are some interviewing mistakes?

Answer 2

1. Not introducing yourself
2. Close-ended questions
3. non-empathetic questions/answers
4. Not listening
5. Not patient-friendly language
6. Too authoritative
7. Leading.suggestive questions
8. Not following-up on vague answers

Question 3

When starting the interview, what are important things to remember?

Answer 3

1. Appropriate body language - eye contact!
2. Open-ended questions/listening
3. Direction/re-direction if off-topic
4. Analyze patient. May have to scare them slightly to drive home importance of health, but not too much.
5. Sensitivity/empathy
6. Cultural sensitivity
7. Negotiation when it comes to setting up plans

Question 4

What are the differences between biomedical and behavioral models of care?

Answer 4

The biomedical model is provider-driven, and gives information in an authoritative fashion. It “saves’ the patient, and is focused on compliance with the set plan. Respect is expected.
In comparison, the behavior model is patient-driven, and information is exchanged rather than given. Behavior is negotiated, and the whole interaction is more of a two-way conversation. Resistance is seen as information about barriers rather than a bad thing. Respect is earned

Question 5

What are the two major components of behavior change?

Answer 5

1. The five stages of change

2. Motivational interviewing

Question 6

What are the five stages of change?

Answer 6

1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

Question 7

Stages of contemplation: I want to change but …

Answer 7

Preparation

Question 8

Stages of contemplation: I can’t change.

Answer 8

Pre-contemplation

Question 9

Stages of contemplation: I’ve already been doing it.

Answer 9

Maintenance, risk of relapse

Question 10

Stages of contemplation: There are good and bad things about change.

Answer 10

Contemplation.

Question 11

Stages of contemplation: I’m already doing it.

Answer 11

Action

Question 12

What is the readiness ruler?

Answer 12

It is a scale of 0-10 to assess the stage of contemplation for change for a patient.

Question 13

What is the confidence ruler?

Answer 13

It is a tool used to measure the confidence level of a patient in their goals that have been set.

Question 14

What kind of question should you ask a patient about their confidence? What does this accomplish?

Answer 14

What would it take to get you to go from a 4 to a 10 in confidence? It reveals possible barriers to goals.

Question 15

What does motivational interviewing accomplish?

Answer 15

It is based upon asking permission, and discovers how ambivalent a person is about the issue. Supporting self-efficacy is important.

Question 16

What is MI? What are the 4 components?

Answer 16

Motivational interviewing: REDS

1. Roll with resistance
2. Express empathy
3. Discover discrepancy
4. Support self-efficacy

Question 17

When a patient is resistance, what is an appropriate response?

Answer 17

Change your method, clarify reason for resistance. Opt for understanding.

Question 18

What are positive ways to express empathy to a patient?

Answer 18

Active listening, with good eye contact. Repeating back, nodding, understanding.

Question 19

How can you develop discrepancy?

Answer 19

State pros and cons: What is the best or worst thing that could happen to you if you don’t change?

Question 20

What does creating discrepancy do for the patient?

Answer 20

It helps develop goals for the patient, and supports motivating them.

Question 21

What is something that you can do to support self-efficacy?

Answer 21

ASK the patient what they want. Elicit-Provide elicit. Point out positive thoughts, and use the confidence ruler.

Question 22

Is reassurance a good tool to use in interviewing?

Answer 22

It is to a degree, you don’t want to say that everything will be alright when you cannot deliver that promise. Only promise what you can control.

Question 23

What are some other tools to use in interviewing?

Answer 23

Validation, summarizing, echoing.

Question 24

What can you say to a patient that is silent?

Answer 24

Ask them if a different topic would be better to talk about.

Question 25

What can you say if a patient is confusing?

Answer 25

Try to clarify what they are saying, and have them confirm it. Write it down for later if it is confusing.

Question 26

If a patient is very talkative, should you encourage them?

Answer 26

It depends on the situation. If you are their only personal interaction, connection is good, even on a personal level. It is important to redirect after a time, especially if there are other people waiting in line that need your attention.

Question 27

If a patient is crying, what is the best way to professionally empathize?

Answer 27

Get them a tissue.

Question 28

Dealing with an angry patient: what should you do?

Answer 28

1. Listen
2. Stay calm
3. Be professional
4. Ask them what you can do to help the situation
5. Stick up for yourself and not be rude

Question 29

What are the 3 general reasons you need to document?

Answer 29

1. Liability
2. Continuity of care
3. Getting paid