Patient health history and communication

Medical assistants are directly involved in gathering information from patients about their health. It is important to remember that a healthy state is more than the absence of disease. The assessment process should be a reflection of the entire patient, not just a report about signs and symptoms. Personal lifestyles and environmental factors can cause disease and should be considered when information is gathered about the patient’s chief complaint. For example, patients who smoke or work in stressful occupations may be more prone to hypertension.

Health professionals should consider all patient factors when gathering information about the patient’s health status. The method of analyzing all factors that may contribute to the development of disease is based on a holistic perspective. Holistic patient care recognizes that illness is the result of many factors, not just physical ones.

As the first step in treating a disease process, the provider must determine the patient’s medical diagnosis. A differential diagnosis considers which one of several diseases may be producing the patient’s symptoms. The possible causes for a set of symptoms are considered in order to arrive at a diagnosis. For example, if a patient presents with moderate to severe knee pain, the provider might consider causes such as an injury or arthritis. A differential diagnosis is based on information gathered from the patient about symptoms, contributing family, personal, and social histories, and a complete physical examination. Multiple causes are not ruled out in a differential diagnosis because patients can be sick with more than one thing at once. Once all possible factors have been considered, the provider comes up with a working diagnosis and begins treatment. A working diagnosis is also called a clinical diagnosis. The clinical diagnosis is arrived at after taking a detailed history and doing a comprehensive physical examination, but before any laboratory tests or x-rays, diagnostic testing is done. For the patient with knee pain, after gathering detailed patient information and conducting a comprehensive physical examination, the provider decides that the clinical diagnosis is arthritic changes in the joint. The provider orders x-rays and a magnetic resonance image (MRI) of the knee to confirm the clinical diagnosis. The final diagnosis is determined after all diagnostic studies are completed.

However, patient care does not start with the physical examination; it begins when the patient first contacts the office. Even before the examination, the medical assistant has the opportunity to interact with the patient to ensure comfort during the process and that all of the necessary information is obtained.

Interviewing patients, assisting with examinations, and preparing documentation are important responsibilities for a medical assistant. You must know the components of a medical history and the techniques for interviewing patients to help the provider diagnose and treat the patient. The more complete the medical history, the better the provider will be able to treat the patient.

A medical assistant must also know how to best assist the provider during the physical examination. Understanding what supplies and instruments are needed will make the visit go more smoothly for both the patient and the provider. During a complete physical exam, the patient is placed in various positions to facilitate examination. It is often the medical assistant’s responsibility to assist the patient into the correct position and drape him or her for modesty.

Health history

Health history information is crucial to providing the best possible care to patients. Without knowing what has gone on in the past, it will be harder for the provider to determine the most appropriate course of action. Often, the medical assistant is responsible for collecting the health information initially. It is important to fully understand the forms used to collect this information and the components of a comprehensive health history.

Collecting the history information

A new patient is asked to complete a health history form. This form is useful for diagnosing and treating the patient. This self-history also allows the patient to be more involved in the process. The form may be mailed to the patient’s home before the appointment or may be completed in the office during the first visit. Some healthcare facilities use electronic forms. These can be emailed to the patient before the first appointment and incorporated into the patient’s electronic health record (EHR) when the completed form is emailed back. The patient may also be able to complete the form online through a patient portal. If a paper form is used, it can be scanned into the patient’s EHR after it is completed.

If you are responsible for taking a portion of the medical history, conduct the interview in a private area, free of distractions and where others cannot overhear anything. Patients will not talk freely where they may be overheard or interrupted. Legally and ethically, the patient has the right to privacy, and access to the patient’s health record is permitted only for healthcare workers directly involved in the patient’s care or individuals the patient has specified on his or her **Health Insurance Portability and Accountability Act (HIPAA) **complaint records release form. Listen to the patient. Do not express surprise or displeasure at any of the patient’s statements. Remember, you are not there to pass judgment but collect medical data. The medical assistant should document the information in an organized manner, exactly as given by the patient, without opinion or interpretation. The documentation should include the following:

• Purpose of the patient’s visit, written as the chief complaint (CC)
• Patient’s vital signs (VS)
• Height and weight
• Pain; documented using a scale of 1 to 10, with 1 being the least amount of pain and 10 being the greatest amount
• In some facilities, the provider takes the medical history during the patient’s initial visit. The provider correlates the physical findings in the examination with the information in the history. The complete medical history and the physical examination are the starting point and foundation of all patient-provider contacts. EHR systems directly incorporate the patient’s history and physical examination data into the health record.

Components of the health history

Health history forms vary depending on the provider’s preference, the practice specialty, and the EHR system used in the facility. The most commonly used health history forms include these components:

• Demographics: The record of the patient’s demographic information, history, physical examination, and initial laboratory findings. As new information is added, it becomes part of this database.
• Chief complaint (CC): The purpose of the patient’s visit. Generally, this is documented in the patient’s own words.
• History of present illness (HPI): The medical assistant should gather as much information about the health problem as possible and document it concisely in chronological order. The documentation should include the following descriptions:
• Location: What area of the body is the current condition located in? (Have the patient point to the area.)
• Quality: How would the patient describe the condition? If there is pain, is it sharp, dull, ache, intense, cramp, nagging, burning?
• Severity: What is the severity of pain? (Pain is usually documented using a scale of 1 to 10 with 10 being the worst.)
• Duration: How long has the condition been going on?
• Timing: How long does it last when it occurs?
• Context: What was the patient doing when she or he first noticed the condition?
• Modifying factors: What makes it better or worse? Does it occur while standing, sitting, laying down, sleeping, or while eating? Does anything help (like Tylenol)?
• Signs and symptoms: What other signs and symptoms occur with the condition (such as headache with blurred vision, back pain with numbness and tingling down the leg, or frequency and urgency with urination)?

Past history (PH) or past medical history (PMH): A summary of the patient’s previous health. It includes dates and details about the patient:

• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Immunization Records
• Accident History

Allergy documentation

Each medical practice has a policy on how to document a patient’s allergies. In a paper record, they typically are noted in red ink or identified by a colored sticker so that all healthcare workers can easily see them. EHR systems have methods for including allergy information on all pertinent screens in the patient’s record.

The patient’s medication history should include a record of currently prescribed drugs and frequently used over-the-counter (OTC) medications, including supplements.

• Family history (FH): Details about the patient’s parents and siblings and their health; if they are deceased, the age and cause of death. This information is important because certain diseases and disorders have familial or hereditary tendencies.
• Social history (SH): This section includes information about the patient’s lifestyle:
• Whether the patient feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history: This section includes information about whether the patient sees a dentist regularly and what, if any, dental issues the patient has.
• For female patients, woman’s last menstrual period (LMP), pregnancy history, and method of birth control if sexually active.
• It may be important to note the patient’s cultural and religious background because these factors could influence certain lifestyle and dietary choices. This information helps the provider plan treatment for the patient or determine causative factors for disease. It also provides a holistic picture of the patient’s health. To meet the requirements of Meaningful Use, providers are required to collect information on allergies, patient history, safety at home, and alcohol use.
• Systems review (SR) or review of systems (ROS): These questions provide a guide to the patient’s general health and help detect conditions other than those covered under the present illness. Often a patient may think certain health problems are irrelevant and fail to mention them. However, these problems may help the provider determine the cause of the disorder currently being explored. A systems review is obtained through a logical sequence of questions about the state of health of body systems, beginning with the head and proceeding downward. The provider typically completes this medical history section while conducting the physical examination.