Obtaining A Medical History Chapter 34 Obtaining A Medical History A medical history provides the physician with valuable information. A medical history gives information about a patient’s present and past health and medical treatments. A medical history is obtained from all new patients in a medical office. 1

Medical History Form Provides data or information about a patient Used to: Correlate patient’s symptoms Formulate treatment plan Foundation tool for understanding a patient’s health status Can be simple or comprehensive Many different types of forms Define treatment plan. Show the students various types of medical history forms. 2

Procedure: Completing a Medical History Form Task: obtain and record a patient’s medical history Use verbal and nonverbal communication skills Document accurately in patient’s chart Demonstrate Procedure 34-1. Have the students practice Procedure 34-1. How long does it take to complete a medical history form? 3

Sections of the Medical History Demographic material Chief complaint (CC) Present illness (PI) Past history (PH) Family history (FH) Social history (SH) Review of systems (ROS) Have the student locate each section on a medical history form. Why does the medical history form have sections? 4

The Chief Complaint (CC) Define chief complaint. Explain the difference between signs and symptoms. Explain the difference between subjective and objective information. Give examples of subjective and objective information. Give examples of signs and symptoms and ask students to classify each example as either a sign or symptom. 5

Objective and Subjective Information that can be measured or observed Reports from laboratory, blood pressure reading, elevated temperature, cut, or a rash Subjective Information that cannot be seen or measured Personal data such as throbbing headache, stomachache All objective information must be documented. Not all subjective information will have quotes. Give more examples of subjective information and objective information. 6

Present Illness Expansion of the chief complaint Includes more description about: The current illness or injury The severity of the pain Whether symptoms have gotten better or worse Sometimes the PI is based on past medical problems. Give examples of present illnesses. 7

Descriptions of Pain Have the student practice charting a chief complaint. Have the student practice charting a present illness. Review the differences between chief complaint and present illness. 8

Records Release Why is a record release necessary? When should a medical assistant obtain a record release? For how long is a record release valid? 9

Past History (PH) Summary of the patient’s prior health Past diseases, conditions, or injuries can affect a person’s state of health Includes: Childhood diseases, allergies Major or chronic illnesses Surgeries, hospitalizations Accidents or injuries, last examination date Current and past medication, immunizations Past history is needed to assist the physician in treating the patient’s current problem. Why is it mportant to obtain information on a nonprescription drug? The medical assistant should also ask the patient what herbs he or she takes, if any. 10

Medical History Form Review the sections of the medical history form. What sections of the medical history form should the medical assistant obtain from the patient? What sections of the medical history form will the physician complete? 11

Family History (FH) Health inventory of patient’s blood relatives Mother, father, brothers, sisters, maternal and paternal grandparents Current state of health Significant health history Causes of death for deceased family members Define heredity and familial. Give examples of hereditary and familial diseases. 12

Social History (SH) Picture of the patient’s lifestyle Smoking, eating, drinking, drugs, occupation, and sexual habits May provide insight as to the patient’s ability to comply with treatment May help pinpoint the etiology of the disease Social history information may be awkward to obtain. Demonstrate asking questions regarding the social history in an empathetic, professional manner. Give examples of social history information. 13

Review of Systems (ROS) Systems review of each body system, past and present Usually completed by physician during physical assessment of patient Health questionnaire is completed by patient Medical assistant reviews with patient Review of symptoms is also called systems review. OS is a step-by-step review of each body system. ROS starts at the head and moves downward. 14

Review of Symptoms Which of the following is objective information? Which of the following is subjective complaints? 15

Review of Systems (cont.) Which of the following is objective information? Which of the following is subjective complaints? 16

Medical History and Review of Systems Review each section. Why is this information to obtain from a patient? Medical reports come in different formats. 17

Interviewing Skills Interview to obtain patient history Observe and assess patient’s alertness, level of orientation, grooming, and comfort Must convey genuine concern and respect for the patient Must be done in a private area, free from disruptions Good opportunity to establish a trusting relationship with the patient It is rude to a patient when the interview is interrupted. Patient will know when a medical assistant is acting phony. How is a trusting relationship developed with patients? Explain HIPAA. 18

Effective Communication Obtain necessary information about the patient’s medical history Patients are more likely to open up to the medical assistant when privacy is ensured Assures patient that confidential information will be protected How should a medical assistant protect confidential information? Demonstrate using eye contact, being a good listener, and acknowledging the patient. The medical assistant must convey sensitivity towards the patient. 19

Effective Communication During an Interview Encourages patient to provide all of the necessary information Allows interviewer to receive and understand it Allows patient to have confidence in medical assistant’s ability Uses open-ended questions Do not react to personal or “shocking” details the patient may give you. Be respectful and nonjudgemental. Never be reactive. 20

Open-Ended Questions Example of yes-no questions vs. open-ended questions Yes-no: “Do you mean your foot is falling asleep?” Open ended: “Tell me about the numbness.” Why is it important for a medical assistant to use open-ended questions? 21

Procedure: Recognizing and Responding to Verbal and Nonverbal Communication Task: recognize and respond to basic verbal and nonverbal communication Greet the patient Establish a comfortable environment Ask students for examples of verbal and nonverbal communication. Demonstrate Procedure 34-2 Have the students practice Procedure 34-2 22

Procedure: Recognizing and Responding to Verbal and Nonverbal Communication (cont.) Establish topic of discussion Use open-ended questions Observe mannerisms of patient Practice active listening; provide feedback Define active listening and feedback. Why is Procedure 34-2 so important? 23

Patient Interviews Review the patient interview. Have the students provide a sample of a patient interview and charting of the chief complaint. The student needs to make sure everything is spelled correctly on any form or documentation. 24

Accurate Documentation Clear, concise, objective (nonjudgmental), and correct Provides good database for patient information Basis for the physician’s treatment plan Use quotation marks when documenting the patient’s words Pinpoint specific symptoms Avoid generalized statements “5 C’s” of communication If you do not know how to spell a word, look it up in the dictionary. Carry a small pocket dictionary with you if you have difficulty spelling. Explain the “5 C’s” of communication. 25

Specific Symptoms Versus Generalized Statements Example of general statements vs. specific symptoms General: “My hand seems to go numb all the time.” Specific: “When I am working on the computer for more than 15 minutes, my right hand gets numb.” Define general statements and specific symptoms. Why is it important to document patient statements? 26

Recording Observations Report what is seen, heard, felt, or smelled Includes: Patient’s physical appearance Body structure Mobility Behavior Give examples of a patient’s physical appearance, body structure, mobility, and behavior. Why is this information important to include in a medical record? Have the students practice documenting physical appearance, body structure, mobility, and behavior. 27

Use Nonjudgmental Documentation Example of judgmental vs. nonjudgmental charting Judgmental: Lack of good hygiene has caused the patient to have an infected toe. Nonjudgmental: Patient states foot has been sore for several days. Judgmental: The patient appears upset. Nonjudgmental: The patient is crying and wringing her hands. Why should a medical record only contain nonjudgmental documentation? Have the students practice documenting in a nonjudgmental manner, given carious examples of CCs. 28

Documentation Tips Check the name on the chart before writing Use black ink Write clearly and legibly Begin charting with the date and time End with your first initial, last name, and credential Never leave space between end of entry and signature Be accurate Use proper technique for correcting errors Why is it important for a medical assistant to use black ink? Why should there never be a space left between an end of an entry and a signature? The medical assistant’s notes should be concise. Only important information should be recorded. 29

Documentation (Charting) Have the students practice documenting in a medical record. Demonstrate to the students how to correct an error in a medical error. Have the students practice correcting an error in a medical record. 30