Chapter 18; Medical History and Patient Assessment

process of gathering information about the patient in the presenting condition

main reason for the visit to the medical office

relating to the statistical characteristics of populations

referring to a disorder that tends to occur more often and family then would be anticipated solely by chance

referring to traits or disorders that are transmitted from parent to offspring

Health Insurance Portability and Accountability Act

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

a record containing information about a patient's past and present health status

available without a prescription; includes herbal and vitamin supplements

objective indications of disease or bodily dysfunction as observed or measured by the healthcare professional

subjective indications of disease or bodily dysfunction as sensed by the patient

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. 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. Assessment begins with gathering information to determine the patient's problem or reason for seeking medical care. Typically, you ask standard questions and document the patient's responses during the assessment on preprinted forms or in a manner decided by the physician and outlined in the medical office policy and procedure manual.

To complete the patient's medical history, you and the physician work cooperatively with the patient. In some medical practices, medical assistants gather initial patient information by interviewing the patient using a printed list of questions. Other medical offices ask the patient to fill out a standard form before or during their first appointment. In other practices, the physician may prefer to complete the medical history form during the initial patient interview and examination. In this situation, you should be familiar with the form and ready to assist the physician if needed or asked to do so.

The medical history forms used by the office may vary with the practice specialty, most forms are composed of these common elements: • Identifying data (database) • Past history (PH) • Review of systems (ROS) • Family history (FH) • Social history (SH) This information is confidential and protected by the Health Insurance Portability and Accountability Act, or HIPAA, a federal law that protects the privacy of health information. No one except those directly involved in the patient's care may have access to it without the patient's permission.

The demographic information in this section, required for administrative purposes, always includes the patient's name, address, and phone number. It also includes the name, address, and phone number of the patient's employer and insurance carrier and the patient's health insurance policy number, social security number, marital status, gender, and race.

This section addresses the patient's prior health status and helps the physician plan appropriate care for any present illness. Information in this section typically includes allergies, immunizations, childhood diseases, current and past medications, and previous illnesses, surgeries, and hospitalizations.

A thorough review of each body system may elicit information that the patient forgot to mention earlier or thought was irrelevant. Specific questions, such as symptoms or known diseases, related to each system of the body are included in this section.

This section contains the health status of the patient's parents, siblings, and grandparents. This information is important because certain diseases or disorders have some familial or hereditary tendencies. Familial diseases tend to occur often in particular families, whereas hereditary diseases are transmitted from parent to offspring. If any immediate family member is deceased, the cause of death should be documented.

The social history covers the patient's lifestyle, such as marital status, occupation, education, and hobbies. It may also include information about the patient's diet, use of alcohol or tobacco, and sexual history. This information may help the physician understand how present illness, including any treatment, may affect the lifestyle or how the lifestyle may affect the illness. The social history may also provided a guide for patient education, since some behaviors, such as tobacco use or diet high in fat, may not yet be causing illness but can cause illness in the future.

The past history summarizes the patient's prior health status, whereas the family history summarizes the health status of the patients parents, siblings, and grandparents.

As a medical assistant, your primary goal during a patient interview is to obtain accurate and pertinent information. To do this, you need to understand the basic components of communication and to use effective listening skills. You should also use a variety of interview techniques, including reflecting, paraphrasing, asking for examples, asking questions, summarizing, and allowing for silence. The mental or emotional condition of the patient includes observations such as lethargy, crying, tearfulness, and confusion. Judgments made about these observations should NOT be documented in the patient's record because the terminology used (depressed, abused) may be diagnostic, which is out of the scope of training for the medical assistant. In the case of suspected abuse, you should document the observable information in the medical record and alert the physician regarding your suspicions. 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. To safeguard confidential patient information and allow for open communication, conduct the interview and a private and comfortable place. Avoid public areas, such as the reception area, where distractions are likely and where others may hear the patient's answers.

Always begin the interview with a new or established patient by identifying yourself, your title, and the purpose of the interview. The initial impression you make will be a lasting one, so be sure that your demeanor and words communicate genuine respect and concerned. By developing professional rapport, you will gain the patient's confidence and trust in you, the physician, and the office staff. This makes the professional role of the medical assistant as a caring and empathetic health care worker even more important.

As you begin speaking with the patient, you must assess any barriers to communication, such as unfamiliarity with English, hearing impairment, or cognitive impairment. Note the patient's verbal and nonverbal behavior during the interview and adjust your questions if necessary. Avoid using highly technical or medical terminology when conversing with most patients. If the patient has impaired hearing or vision or difficulty understanding or speaking English, adjust your interviewing techniques to fit the patient's needs; however, remember that raising your voice is not necessary and will not improve communication or understanding with these patients.

You should be familiar with the medical history form before beginning the patient interview to promote smooth communication during the interview.

Yes, 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.

During the interview, listen carefully as a patient describes current medical problems to identify signs and symptoms. Signs are objective information that can be observed or perceived by someone other than the patient. Signs includes such things as rash, bleeding, coughing, and vital sign measurements. Signs may also be found during the physician's examination. Symptoms, or subjective information, are indications of disease or changes in the body as sensed by the patient. Usually, symptoms are not discernible by anyone other than the patient. They include complaints such as leg pain, headache, nausea, and dizziness. Observable signs that may indicate that a patient is having these symptoms include facial expressions, such as wincing during pain, holding onto rails or furniture for balance when walking, and gagging.

After recording the patient's medical history and reviewing the information for accuracy and clarity, you must find out exactly why the patient has come to see the physician for this appointment. Ask an open-ended questions to encourage the patient to describe the chain of events leading to this visit. Open-ended questions allow the patient to answer with more than one or two words. When open-ended questions are use to determine the reason for the visit, the patient's answers will reveal the chief complaint. The chief complaint, 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. Once you have obtained the chief complaint, continue to probe for more details to further define the patient's present illness. The present illness includes a chronologic order of events, including dates of onset and any home remedies for other self-care activities, including over-the-counter and homeopathic medications. Over-the-counter medications are those that are available without prescription.

• Chronology. How did this first begin? • Location. Can you explain or show me exactly where the pain is? • Severity. Can you describe the pain? Is the pain constant? • Self treatment. What medications have you taken for the pain? Do they help? • Quality. Does anything that you do make the symptoms better or worse? • Duration. Have you had these symptoms before? After asking several open -ended questions, it may be appropriate to ask closed-ended questions to obtain specific data. Of course, not all patients visit the doctor because they are ill. Some appointments are for routine examinations and tests. In this case, the chief complaint will include a statement about the reason for the visit, however, you should obtain any additional present illness information as appropriate.

A sign is an objective (observable or measurable) indication of disease. An example of a sign is the 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.