1. Lesson Six Health History, Preventative Services
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2. 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.

3. 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

4. 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?”

5. 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