1. Clinical Aspect Medical Office Assisting State the need for a health history. State the need for a health history. Describe the components of the health history and the importance of each. Describe the components of the health history and the importance of each. State the questions that should be included during a health history. State the questions that should be included during a health history. Indicate the accurate method of documenting a health history in a medical record. Indicate the accurate method of documenting a health history in a medical record. Demonstrate accurate written communication skills. Demonstrate accurate written communication skills. Describe the correct documentation of the health history in the Progress Notes. Describe the correct documentation of the health history in the Progress Notes. Explain the difference between signs and symptoms. Explain the difference between signs and symptoms. Differentiate between objective and subjective symptoms. Differentiate between objective and subjective symptoms. Explain the need for confidentiality when obtaining a health history. Explain the need for confidentiality when obtaining a health history.

2. Clinical Aspect Medical Office Assisting The need for a health history Diagnosing and treating the patient Diagnosing and treating the patient Allows the patient more participation in the process Allows the patient more participation in the process The form may be mailed to the patient’s home to complete or can be completed online. The form may be mailed to the patient’s home to complete or can be completed online.

3. Clinical Aspect Medical Office Assisting Describe the components of the health history and the importance of each. Database: Patient’s name, address, date of birth, insurance information, personal data, history, physician examination, laboratory findings. Chief Complaint: Purpose of the patient’s visit

4. Clinical Aspect Medical Office Assisting Past history (PH) or past medical history (PMH): Summary of the patient’s previous health. It includes dates and details regarding the patient’s usual childhood diseases (UCD or UCHD), major illnesses, surgeries, allergies, accidents, and immunization record.

5. Clinical Aspect Medical Office Assisting Family history (FH): Details regarding the patient’s mother and father, their health, and, if deceased, the cause and age of death.

6. Clinical Aspect Medical Office Assisting Social history (SH): Information regarding the patient’s lifestyle, hobbies, entertainment preferences, education, occupation, use of tobacco and alcohol, sleeping habits, methods of exercise, diet, last menstrual period (LMP) for female patients, and method of birth control if the patient is sexually active is noted in this section

7. Clinical Aspect Medical Office Assisting Systems review (SR) or review of systems (ROS): These questions provide a guide to the patient’s general health and help the healthcare worker detect conditions other than those covered under the present illness.

8. Clinical Aspect Medical Office Assisting State the questions that should be included during a health history. State the questions that should be included during a health history. Questions or statements that begin with “Give me an example of…” or “Explain to me about…” or “So what you are saying is…” help patients focus on the chief complaint as well as giving you the opportunity to clear up any misconceptions before documenting patient information.

9. Clinical Aspect Medical Office Assisting Indicate the accurate method of documenting a health history in a medical record. The method used for charting may vary depending on the Healthcare provider’s preference. However, regardless of the type of documentation used, certain charting procedures have been standardized to meet the necessary legalities of maintaining medical records accurately and concisely. Accurate and complete documentation is one of the primary responsibilities of a medical assistant (Figure 14- 12).

10. Clinical Aspect Medical Office Assisting Demonstrate accurate written communication skills Demonstrate accurate written communication skills The ability to document accurately and completely is an essential skill for medical assistants. Demonstrate the correct use of medical terminology, with appropriate abbreviations.

11. Clinical Aspect Medical Office Assisting Describe the correct documentation of the health history in the Progress Notes. Documentation of information gathered while taking the medical history is included in the Progress Notes section of the medical chart. The medical assistant records the information in an organized manner, exactly as given by the patient, without opinion or interpretation. The note should include the purpose of the patient’s visit written as the chief complaint (CC), vital signs (VS) including height and weight if preferred by the physician, and if the patient reports pain it should be documented using a scale of 1 to 10, with one being the least and ten being the most amount of pain. In some facilities the physician takes the medical history

12. Clinical Aspect Medical Office Assisting Explain the difference between signs and symptoms. Explain the difference between signs and symptoms. Subjective findings, or symptoms, are perceptible only to the patient; they are what the patient feels and can be interpreted only by that patient. For example, only the patient experiences and can define the quality of his or her discomfort, pain, nausea, or dizziness. The typical method of recording a complaint of pain is to quantify the pain by asking the patient, “On a scale of 1 to 10, with 1 being the least amount of pain and 10 being the greatest, how would you describe the pain?” Symptoms of the greatest significance in identifying a disease are called cardinal symptoms. For example, crushing chest pain and difficulty breathing are cardinal symptoms for a potential heart attack.

13. Clinical Aspect Medical Office Assisting Objective findings, or signs, can be observed and/or measured by the physician or medical assistant. They are the indicators of health or disease that a physician detects when examining a patient. The physician feels, sees, hears, or measures the signs that are often associated with a certain disease or abnormal condition. For example, a mass that a physician palpates, or feels, in the patient’s abdomen is an objective finding and a sign of an abnormal condition. In addition, objective data can be measured and recorded, and repeat measurements can be taken to confirm the presence of or changes in the sign. Objective signs that the medical assistant measures and records on a regular basis include the patient’s temperature, pulse, respirations, and blood pressure.

14. Clinical Aspect Medical Office Assisting Explain the need for confidentiality when obtaining a health history. Explain the need for confidentiality when obtaining a health history. If you are responsible for taking a portion of the medical history, conduct the interview in a private area free from outside interference and beyond the hearing range of other patients. Patients will not talk freely where they may be overheard or interrupted. The interview room should be physically comfortable and conducive to confidential communications. Legally and ethically the patient has the right to privacy, and access to the patient’s medical record is permitted only to healthcare workers directly involved in the patient’s care or to those individuals the patient has specified on his or her Health Insurance Portability and Accountability Act (HIPAA) release form.

15. Videos for Seminar 2 Leave 15 minutes early, write at least one paragraph on the videos on what you have learned. Dropbox, seminar 2, option 2. Leave 15 minutes early, write at least one paragraph on the videos on what you have learned. Dropbox, seminar 2, option 2. video # 1 for seminar 2 Why OSHA was Created http://www.youtube.com/watch?v=A- TXgSQ-0c4 Bloodborne Pathogens Training Video video # 1 for seminar 2 Why OSHA was Created http://www.youtube.com/watch?v=A- TXgSQ-0c4 Bloodborne Pathogens Training Videohttp://www.youtube.com/watch?v=A- TXgSQ-0c4http://www.youtube.com/watch?v=A- TXgSQ-0c4 VIDEO # 2 http://www.youtube.com/watch?v=BACgi9AoKDU Needle Stick VIDEO # 2 http://www.youtube.com/watch?v=BACgi9AoKDU Needle Stick http://www.youtube.com/watch?v=BACgi9AoKDU VIDEO # 3 http://www.youtube.com/watch?v=rtZTa1sbnSQ VIDEO # 3 http://www.youtube.com/watch?v=rtZTa1sbnSQ http://www.youtube.com/watch?v=rtZTa1sbnSQ