1. Medical History and Patient
Chapter 18:
Medical History and Patient
Assessment

2. Learning Outcomes Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Spell and define key terms
2. Recognize barriers to communication
3. Identify techniques for overcoming communication barriers
4. Give examples of the type of information included in each section of the patient history
5. Identify guidelines for conducting a patient interview using principles of verbal and nonverbal communication
6. Differentiate between subjective and objective information
7. Discuss open-ended and closed-ended questions and explain when to use each type during the patient interview

3. Learning Outcomes (cont'd.)
Psychomotor Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Use feedback techniques to obtain patient information including the following: (a) reflection, (b) restatement, and (c) clarification
2. Use medical terminology correctly and pronounced accurately to communicate information to providers and patients
3. Respond to nonverbal communication
4. Obtain and record a patient history (Procedure 18-1)
5. Accurately document a chief complaint and present illness
(Procedure 18-2)

4. Learning Outcomes (cont'd.)
Affective Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Incorporate critical thinking skills when performing patient assessment
2. Demonstrate (a) empathy, (b) active listening, and (c) nonverbal communication
3. Demonstrate sensitivity to patients rights
4. Demonstrate principles of self-boundaries
5. Demonstrate respect for individual diversity including (a) gender, (b) race, (c) religion, (d) age, (e) economic status, and (f) appearance

5. Learning Outcomes (cont'd.)
ABHES Competencies
1. Be impartial and show empathy when dealing with patients
2. Interview effectively
3. Recognize and respond to verbal and nonverbal communication
4. Obtain chief complaint, recording patient history

6. Introduction
To diagnose a patient’s present illness, the physician needs the patient’s past and current health information. As a professional medical assistant, you are often responsible for obtaining this information as part of the medical history and assessment.
medical history: record containing information about a
patient’s past and present health status
assessment: process of gathering information about the patient and the presenting condition
The medical history is a record containing information about a patient’s past and present health status, the health status of related family members, and relevant information about a patient’s social habits.
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7. The Medical History Methods of Collecting Information
Physician (be ready to assist)
Medical assistant + physician
Patient or medical assistant fills out form
To complete the patient’s medical history, you and the physician work cooperatively with the patient.
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8. The Medical History (cont’d.)
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9. The Medical History (cont’d.)
Health Insurance Portability and Accountability Act (HIPAA): federal law, originally passed as the Kassebaum-Kennedy Act, that requires all health care settings to ensure
privacy and security of patient information. Also requires
health insurance to be accessible for working Americans and available when changing employment
Elements of the Medical History
Form contains confidential information protected by HIPAA
Information collected:
Identifying demographic data
Name
Contact/insurance info
SS#
Marital status
Gender
Race
demographic: relating to the statistical characteristics of populations
The medical history forms used by the office may vary with the practice specialty, but most forms are composed of these common elements: identifying data (database), past history, review of systems, family history, and social history.
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10. The Medical History (cont’d.)
A sample medical history form (front).
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11. The Medical History (cont’d.)
A sample medical history form (back).
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12. The Medical History (cont’d.)
Past history (PH):
Childhood diseases
Prior health status, surgeries, medications, illnesses, hospitalizations
Existing illness and medications, allergies, immunizations
Review of systems (ROS):
Discuss each body system
Specific symptoms
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13. The Medical History (cont’d.)
Family history (FH):
Health status of parents, siblings, grandparents
Familial disease
Hereditary disease
Social history (SH):
Lifestyle, occupation, education, marital status
Diet, alcohol/tobacco use, sexual history
familial: referring to a disorder that tends to occur more often in a family than would be anticipated solely by chance
hereditary: referring to traits or disorders that are transmitted from parent to offspring
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14. Checkpoint Question
An elderly patient asks Steve what is the difference between the past history and the family history. How would Steve explain the difference?
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15. Checkpoint Answer
The past history summarizes the patient’s prior health status, whereas the family history summarizes the health status of the patient’s parents, siblings, and grandparents.
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16. Conducting the Patient Interview
Preparing for the Interview
Goal — obtain accurate and relevant patient information
First step — prepare for interview
Know active listening techniques:
Reflecting
Paraphrasing, summarizing
Asking for examples
Asking questions
Allowing silence
Communication also includes observation
As a medical assistant, your primary goal during a patient interview is to obtain accurate and pertinent information.
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17. Conducting the Patient Interview (cont’d.)
Review medical history
Conduct interview in private
Observe patient — note objective condition:
Physical — general appearance
Emotional — crying/tearful, lethargic
Avoid diagnostic terms such as depressed, abused
Conduct the patient interview in a private office or exam room.
Before you start interviewing the patient, make sure you are familiar with the medical history form and any previous medical history provided by the patient.
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18. Conducting the Patient Interview (cont’d.)
Introducing Yourself
Give your name and title
State purpose of interview
Emphasize confidentiality
Behave professionally and respectfully — build trust
Display caring and empathy
Under no circumstance should you identify yourself as a nurse because it is unethical and illegal to give the patient a false impression of your credentials.
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19. Conducting the Patient Interview (cont’d.)
Barriers to Communication
Language — unfamiliar with English
Hearing — impaired
Cognitive — impaired
Avoid jargon or technical terminology
Face patient
Maintain eye contact
Note the patient’s verbal and nonverbal behavior during the interview and adjust your questioning if necessary.
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20. Checkpoint Question
Steve takes a few minutes to look over the medical history form before going into the exam room to interview a new patient. Why is it important to review the medical history form before beginning the interview?
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21. Checkpoint Answer
You should be familiar with the medical history form before beginning the patient interview to promote smooth communication during the interview.
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22. Checkpoint Question
Why should you let the patient know that any information shared during the interview will be kept confidential?
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23. Checkpoint Answer
It is important to let the patient know that any information shared during the interview will be kept confidential. Understanding this enables patients to trust in the medical staff and encourages them to share important information that allows the physician to provide better care for the patient.
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24. Assessing the Patient Signs and Symptoms Signs: Rash Bleeding Coughing
Vital signs
Found during physician examination
signs: objective indications of disease or bodily dysfunction
as observed or measured by the health care professional
Signs are objective information that can be observed or perceived by someone other than the patient.
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25. Assessing the Patient (cont’d.)
Symptoms:
Pain
Headache
Nausea
Dizziness
Can be observed in patient reactions — wincing, gagging, holding onto objects while dizzy
symptoms: subjective indications of disease or bodily
dysfunction as sensed by the patient
Symptoms, or subjective information, are indications of disease or changes in the body as sensed by the patient.
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26. Assessing the Patient (cont’d.)
Chief Complaint (CC) and Present Illness (PI)
Chief complaint:
Includes signs and symptoms
Documented in medical record as a progress report
chief complaint (CC): main reason for the visit to the medical office
Open-ended questions allow the patient to answer with more than one or two words.
The CC, which is one statement describing the signs and symptoms that led the patient to seek medical care, is documented in the patient’s medical record at each visit.
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27. Assessing the Patient (cont’d.)
Present illness:
More specific information:
Chronology
Location
Severity
Self-treatment (over-the-counter drugs, homeopathic remedies)
Quality
Duration
over-the-counter (OTC): available without a prescription; includes herbal and vitamin supplements
homeopathic: referring to an alternative type of medicine in which patients are treated with small doses of substances that produce similar symptoms and use the body’s own healing abilities
Avoid suggesting answers with questions such as “Is the pain sharp?” or “Is the pain worse when you walk?”
In addition, do not coax patients by making suggestions of symptoms you might expect them to have based on the chief complaint.
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28. Assessing the Patient (cont’d.)
Open-ended — patient answers in more than a few words
Should be asked before closed-ended questions
Patient’s description in own words
Help develop chief complaint
Closed-ended — patient answers in one or two words
Should be asked after open-ended questions
Obtain specific data about present illness
Avoid questions that suggest answers
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29. Checkpoint Question
Explain the difference between a sign and a symptom, and give one example of each.
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30. Checkpoint Answer
A sign is an objective (observable or measurable) indication of disease. An example of a sign is a patient’s blood pressure, temperature reading, or noting a laceration or rash on the patient’s skin.
A symptom is a subjective indication of disease that is felt or noticed by the patient but not directly observable or measurable by the medical assistant or physician. Examples of symptoms include headache, nausea, and pain.
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