The Medical History and Patient Screening Chapter 37 The Medical History and Patient Screening

Patient Screening The process of obtaining information and determining the best action to take (and in what priority) Types: Phone, In-person Originated from the concept of triage Used by the military Prioritizing the conditions of the injured following a disaster

In-Person Screening Performed in a private area or exam room Requirements Professional communication skills Privacy and confidentiality Follow the Patient Bill of Rights

In-Person Screening Goals Find out why the patient is seeking health care Determine the patient’s main problem (CC) Note any other patient concerns Discover what remedies or treatments the patient has already tried

Factors Influencing Screening Be aware of your biases and nonverbal cues Be open when approaching patients Treat all patients with respect, regardless of age, religion, race, or financial status Establish a non-threatening environment Ensure patient understanding

Conducting In-Person Screening Use open-ended questions Patient will have completed a health history form Let the patient do most of the talking Ask what brought the patient to the office Develop the chief complaint Document in the chart or EMR Conclude with a summary

The Health History Includes all information about the patient and the patient’s family Acquired from all new patients Purpose of the health history Basis for understanding present health status Basis for guiding treatment from the provider Can provide statistical data

Reviewing the History Form Provide a private area Introduce yourself and build rapport Review information with patient for clarity and completeness Ensure clear communication Use effective techniques

Sections of the Form Chief complaint The reason the patient is seeking care at that visit Use the patient’s language Should include subjective symptoms and objective findings Subjective: Symptoms or feelings that only the patient can perceive Objective: Symptoms or information that can be observed

Sections of the Form Present illness and history of present illness Medical history and past medical history All problems, surgeries, illnesses, disorders that have ever been diagnosed Include usual childhood diseases Current medications Any known allergies

Sections of the Form Family health history Age and health status Immediate family, grandparents, aunts and uncles Social and occupational history Patient’s personal or lifestyle habits May be sensitive in nature Work history, drug usage, living environment, hobbies, diet and exercise

After the History is Complete Take patient’s mensurations and vital signs Prepare the patient to be seen by provider Provider performs a Review of Systems Systematic check of each body system Provides a baseline for future visits Documented on the health history form