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Patient Interview and History Chpt. 36 389-409

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Term
Definition
Information contained in a medical record becomes;   A legal document for the treatment of the patient  
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HIPPA - Health Insurance Portability and Privacy Act standards include;   1.Medical Information Disclosure Practices 2.Release of Medical Information waiver 3.Notice of Privacy Practices  
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A written authorization is required from the client BEFORE;   Disclosure of Information is given  
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A NPP - Notice of Privacy Protection must be posted in;   Clear and prominent locations  
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HIPPA violations can result in:   1.$250,000 fine 2.Incarceration for 10 years 3.Civil litigation by those whose information you disclosed  
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Effective communication methods include:   1.Asking open-ended questions 2.Mirroring the patients responses 3.Focusing on the patient 4.Encouraging the patient to take the lead 5.Encouraging the patient to evaluate their situation  
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Example: Asking open ended question   Can you tell me what you have been feeling?  
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Example: Mirroring a patients responses   So the pain started about three days ago and has been getting worse each day?  
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Example: Focusing on the patient   Maintain eye contact and block out distractions  
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Example: Encouraging the patient to lead the conversation   Where would you like to begin?  
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Example: Encouraging the patient to evaluate their situation   What do you think is going on here?  
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Created by: adrouillard
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