Things Every Medical Assistant Must Do When Taking Patient Histories
When you become a medical assistant, one of the tasks you will likely be assigned is taking patient histories. What is a patient history? Like its name implies, a patient history is a record of a patient's medical past, including previous illnesses, surgeries and vaccinations. But it also notes any current symptoms, complaints or other issues that may require the doctor's attention.
As a medical assistant, you will likely only create histories for new patients. For returning patients, you will only need to update their histories with information about any new illnesses they've suffered, surgeries they've had or medications -- prescription or over-the-counter -- they've taken regularly since their last visit.
If you have a standard patient history form to fill out, getting a personal history is fairly simple and straightforward. Even so, there are five things you must do if you are to get a history that is accurate and helpful to both patient and physician.
Here are the five things every medical assistant must do when taking a medical history:
1. Establish a rapport. Before any questioning begins, a little small talk will help "break the ice." Be welcoming, upbeat andntroduce yourself by name. Ask the patient about his/her day. Explain what you're about to do and why you're doing it. Don't be mysterious. You'll get better, more truthful information if you have your patient's trust.
2. Follow the protocol. You will probably have a standard medical history form to fill out for each new patient. Follow the form you're given and fill it out as completely as you can. Don't jump over sections or assume you know what the patient is going to say. Be thorough.
3. Ask for details. Like the saying goes, the devil is in the details. If a patient has had previous illnesses or surgeries, ask for dates. If the patient is taking prescription medications, over-the-counter drugs or dietary supplements, ask for dosages and frequencies. Don't press too hard here. Patients often don't remember specific dates or dosages, and you don't want to intimidate them. Dig only as deeply as you both feel comfortable.
4. Don't appear judgmental. This is the difficult part, and it is the one that takes the most practice. When taking a medical history, you'll be covering territory that is often personal, intimate and perhaps even embarrassing. This is particularly true when discussing sexual issues and recreational drug use. When asking questions and responding to answers, you need to stay composed, attentive, sympathetic and supportive. It's never considered appropriate to laugh, cringe, gag or otherwise communicate through sound or body language that you find a response funny or distasteful. You never want a patient to feel mocked or otherwise ill-at-ease.
5. Don't offer opinions or advice. Often, a patient will ask you to make a medical judgment about a matter being discussed. You cannot share your opinions, except perhaps when proclaiming a body temperature, pulse rate or blood pressure reading "normal," even if asked. On matters anything more complex than these, your best default response is, "The doctor will be happy to discuss that with you." This not only protects you, but also protects the patient from receiving potentially false or contradictory advice/information.