Lesson Six Health History, Preventative Services WE’RE READY TO HELP! For customer support, please call us at 1-800-222-9570 or visit our online technical support center at evolvesupport.elsevier.com to access self-service options or chat with a live representative.

HEALTH HISTORY, PREVENTATIVE SERVICES Collecting Health Information »» Provided by patient documented or documented by medical assistant »» Mailed to patient’s home before appointment or completed during first office visit »» Conduct patient interview in private area Collecting Medical Information »» Interview room »» Comfortable and conducive to confidential communication »» Remain professional and neutral to patient statements »» Record information in an organized manner and exactly as stated by patient, without opinion or interruption »» CC, vital signs, weight, height, pain scale, etc.

HEALTH HISTORY, PREVENTATIVE SERVICES »» Past Medical History (PMH) »» Past hospitalizations, surgeries, pregnancy »» Social History (SH) »» Occupation, smoking status, alcohol use, hobbies »» May be contributing risk factor for health problems »» Family History (FH) Interview barriers »» Giving advice without physician approval »» Using excessive medical terminology »» Talking too much »» Rushing the patient

HEALTH HISTORY, PREVENTATIVE SERVICES Interviewing: Open-Ended Questions »» Designed to give the patient the opportunity to provide additional information »» “What brings you to the office today?” »» “How have you been feeling?” »» “Tell me more about your symptoms.” Interviewing: Close-Ended Questions »» Asked for specific information that can be answered with only a few words »» “Do you have a headache?” »» “What is your birth date?” »» “Have you ever broken a bone?”

HEALTH HISTORY, PREVENTATIVE SERVICES Signs and symptoms »» Signs »» Objective findings »» Measured, inspected, palpated, auscultated, or manipulation »» “Tell me more about your symptoms.” »» Symptoms »» Subjective findings »» Patient complaints regarding how he or she feels »» Measure pain on a scale of 1 to 10 Preventative Services »» Wellness measures based on patient’s gender and age »» Mammograms, colonoscopy, flu shots »» Dental and vision services