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Mistakes to Avoid When Taking a Patient’s History

Medical Assistant Takes Patient History In HospitalTaking a patient’s medical history is an important part of any clinical medical assistant’s job. You must take this process seriously to gather all the information doctors need to provide informed care. So how can you make sure patient history work is done properly? Here, the Prism Career Institute provides some helpful tips for those looking to enter the medical assistant profession.

Lack of Communication

Patients need you to help them open up. If you just start asking questions, they’ll feel like you’re more machine than human. Instead, introduce yourself and ask permission to ask them a few questions. Throughout your time with them, make sure they feel comfortable asking questions of you as well. After all, they may be in pain and potentially nervous. Taking a compassionate, communicative approach will put them at ease and help them answer questions more accurately and fully.

At the same time, it’s important to thank patients when you’re finished collecting information and let them know the doctor will see them shortly. Doing so will help them feel informed and more relaxed.

Overlooking Symptoms

When you work with ill and injured people all day, you’re likely to hear about the same symptoms, aches, and pains repeatedly. Keep in mind, however, that these experiences are new and often scary for each patient. It’s important to investigate each complaint and take all of the factors into account. Be sure to help patients fully express their concerns by using the SOCRATES method to ask about each symptom’s:

  • Site: Where is the pain or injury located?
  • Onset: How often does it hurt? Is it constant or intermittent?
  • Character: How would you characterize the pain? Is it sharp or burning?
  • Radiation: Does the pain move throughout the body or stay in one spot?
  • Association: Are there other symptoms involved, such as vomiting or sweating?
  • Time course: Have they noticed any pattern of pain?
  • Exacerbating/relieving factors: Does anything make the pain better or worse?
  • Severity: How strong is the pain (consider using a scale from 1 to 10)?

By covering every aspect of the patient’s symptoms, you can provide the doctor with a fuller picture to support diagnosis and treatment.

Failing to Be Thorough

If you focus only on current symptoms and neglect past medical history or family history, you won’t be giving the doctor the necessary details. Past medical history lets the doctor know if the current pain is part of a larger issue, and family medical history can alert them to potential illnesses and disorders that may factor into the current situation.

Similarly, if you forget to ask about any prescriptions and over-the-counter medications the patient takes, the doctor won’t be able to consider potential interactions with the medications he or she prescribes. Finally, it helps to learn if the patient has someone to help care for them at home after an injury or serious illness. If not, the doctor may suggest they be admitted to the hospital as a precaution.

Learn More by Applying to Our Program

Accurate, detailed patient history work is just one of the invaluable tasks performed by medical assistants in clinics, hospitals, and more every day. If you’re interested in learning more about this rewarding profession, contact Prism Career Institute to request information about our Medical Assistant program in Cherry Hill and Egg Harbor, New Jersey. Ready to get started? Apply online today.