Health History and Documentation Objectives

Question 1

Be able to recognize and avoid common interviewing mistakes

Answer 1

Asking close ended questions, not picking up on cues, not being empathetic, not using patient friendly language, not introducing yourself, not listening to the patient, asking suggestive/leading questions, cutting the patient off, suggesting vague answers, or using the authority position

Question 2

Know the proper steps to take before the interview

Answer 2

Make sure you’re dressed appropriately, review charts/patient profiles, make the environment comfortable, introduce yourself, and establish the reason for the visit

Question 3

The biomedical model of healthcare

Answer 3

The biomedical model is practitioner centered and focuses on information giving and trying to “save” the patient. It dictates patient behavior and demands compliance using an authoritarian position where respect is expected. It attempts to motivate the patient by persuading and manipulating them. It feels that resistance is bad and arguments ensue if there is a disagreement

Question 4

The behavior model of healthcare

Answer 4

The behavior model is patient centered and focused on information exchange. The patient saves themselves and the patient and provider negotiate behavior. The clinician acts as the servant, and works with the patient to develop a plan they want to be adherent to. The provider assesses motivation and attempts to understand and accept the patient’s point of view. Resistance is information, but the provider is still willing to confront the patient if there is a problem. The provider earns the patient’s respect instead of expecting it.

Question 5

Be aware of interviewing tools and how to best use them

Answer 5

Elicit-provide-elicit, using graded responses, continuers, echoing, summarize, validation, reassurance

Question 6

Be able to list and explain the 5 stages of change

Answer 6

Precontemplation, contemplation, preparation, action, and maintenance/relapse

Question 7

Understand what the readiness ruler and confidence ruler do and when to use them

Answer 7

Asks how important/confident the patient is to change it. Why are you at ___ and not zero? What would it take for you to go from ____ to a (higher number)?

Question 8

The four general concepts of motivational interviewing

Answer 8

Roll with resistance, express empathy, develop discrepancy, and support self-efficacy.

Question 9

Roll with resistance

Answer 9

get clarification, ask for their perspective and try to understand it, and resistance means you need to change your method

Question 10

Express empathy

Answer 10

active listening techniques and understanding

Question 11

Develop discrepancy

Answer 11

make the patient create the pros and cons, restate the discrepancy, this way motivation is created on the part of the patient

Question 12

Support self-efficacy

Answer 12

ask them what the change should be, point out their positive thoughts and choices, confidence ruler, elicit-provide-elicit

Question 13

How to deal with a silent patient

Answer 13

try a new topic

Question 14

How to deal with a confusing patient

Answer 14

paraphrase and re-direct to one topic

Question 15

How to deal with a crying patient

Answer 15

don’t make promises you shouldn’t; get them a tissue

Question 16

How to deal with an angry patient

Answer 16

ask them what you can do to help

Question 17

How to deal with a patient with altered capacity

Answer 17

ask permission to talk to other people

Question 18

How to deal with a talkative patient

Answer 18

direction and re-direction

Question 19

What is the reasoning for SOAP documentation?

Answer 19

Liability, communication, proof, and reimbursement

Question 20

Subjective portion of SOAP note

Answer 20

what the person tells you and the medication list

Question 21

Objective portion of the SOAP note

Answer 21

things you observe, diagnostics, labs, vitals, and results of the physical exam

Question 22

Assessment portion of the SOAP note

Answer 22

discussion of differential diagnosis, rule out other possibilities, discussion of chronic diseases and adherence

Question 23

Plan portion of the SOAP note

Answer 23

place to discuss therapeutic options/changes, future things to be worked on, things that are ordered to be completed, instructions for follow up, and patient education

Question 24

Comprehensive documentation

Answer 24

for a new patient; contains baseline information and helps with differentials; includes a full physical

Question 25

Focused documentation

Answer 25

for established patients or urgent care/ED; it’s for acute conditions when you’re short on time and can only do an exam of the symptomatic body system

Question 26

Medication therapy management documentation

Answer 26

systematic review of patient specific information (MTR), list of medications for patient use (PMR), patient-centric document containing a list of actions (MAP), intervention and/or referral, and documentation