The content of the health record
Past health, family, and social history
The patient’s health record is the most important record in a provider’s practice. For completeness, each patient’s record should contain subjective information provided by the patient and objective information obtained by the provider and staff of the healthcare facility.
A patient’s past health, family, and social history is often obtained by having the patient complete a questionnaire. The medical assistant may review the form for completeness and clarify any questions or missing information with the patient before the patient is seen by the provider. The provider will also augment this history with information provided during the patient interview.
The responses provide information about any past illnesses (including injuries and/or physical defects, whether congenital or acquired), hospitalizations, or surgeries the patient has had. It also includes information about the patient’s daily health habits.
Past health history
The past health history will include information about previous illnesses/injuries (including childhood illnesses such as chickenpox or measles), previous hospitalizations, and previous surgeries. The dates that these occurred will need to be documented, as well as any complications. The provider needs to be aware of this information because it could affect the patient’s current condition.
Family history
The family history comprises the physical condition of the various members of the patient’s family, any illnesses or diseases individual members may have had, and a record of the causes of death.
Most providers are interested in the immediate family: parents, grandparents, siblings, and children.
Social history
The social history includes information about the patient’s lifestyle.
If the patient drinks alcohol, how many drinks per day or per week are consumed? If the patient uses nicotine, how much is used in a day, and what type (i.e., cigarettes or smokeless tobacco)? Drug use, living situation, exercise, and nutrition information can be considered part of the patient’s social history.
Patient’s chief complaint
The patient’s chief complaint is a concise account of the patient’s symptoms, explained in the patient’s own words.
It should include the following:
- The nature, location, frequency, and duration of pain, if any
- When the patient first noticed the symptoms
- Treatments the patient may have tried before seeing the provider and whether they have helped with the symptoms or not; when the last dose was taken
- Whether the patient has had the same or a similar condition in the past
- Other medical treatment received for the same condition in the past
Most medical facilities use a pain scale to determine the severity of the patient’s discomfort.
The pain scale or wording used in individual facilities should be documented in the office policy and procedures manual and followed by the medical assistant.
Objective information
Objective findings, sometimes referred to as signs, are findings that can be observed and measured. They can include vital signs, measurements, and observations made by the medical assistant and findings from the provider’s examination of the patient.
Vital signs and anthropometric measurements
The medical assistant’s responsibilities include taking the patient’s vital signs (i.e., temperature, pulse, respirations, blood pressure, pulse oximetry) and height and weight. These measurements are documented in the patient’s health record and are used by the provider in his or her assessment. If the medical assistant observes other signs such as a rash, this would also be documented in the patient’s health record and brought to the provider’s attention.
Findings and laboratory and radiology reports
After the provider has examined the patient, the physical findings are documented in the health record. The results of other tests or requests for these tests are then documented or, if they appear on separate sheets, are attached to the health record. When an EHR is being used the separate sheet may be scanned so that it is in an electronic format and can be added to the patient’s EHR.
Diagnosis
Based on all the evidence provided in the patient’s past history, the provider’s examination, and any supplementary tests, the provider notes his or her diagnosis of the patient’s condition in the health record. If some doubt remains, this may be labeled a provisional diagnosis.
For example, the differential diagnosis of rhinitis, or a runny nose, could indicate allergic rhinitis (i.e., hay fever), the common cold, or even abuse of drugs or nasal decongestants.
Treatment prescribed and progress notes
The provider’s suggested treatment is listed after the diagnosis. Generally, instructions to the patient to return for follow-up treatment within a specific period also are noted here. If surgery or other treatment is going to be performed during the current visit, the patient must sign a consent form.
On each subsequent visit, when using a paper record, the date must be entered on the record; information about the patient’s condition and the results of treatment, based on the provider’s observations, must be added to the health record. Notations of all medications prescribed or instructions given, and the patient’s own report of how they are doing, should be documented in the health record.
If the patient is hospitalized, the name of the hospital, the reason for admission, and the dates of admission and discharge are documented.