1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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