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Tips for Taking Patient History

Assistant Taking Patient HistoryAs a medical assistant, one of your primary responsibilities involves taking medical patient history. When you graduate from the Prism Career Institute and prepare to begin working at a hospital or clinic, it’s important to follow best practices. Oftentimes, you’re one of the first people to interact with the patient, so you want to make them feel welcome and comfortable. You also want to make sure you’re recording everything they tell you as accurately as possible, so that the doctor has all the information he or she needs. Here are some tips to keep in mind.

Following a Structure

While taking a patient’s history, there’s a lot of information you need to gather in just a short amount of time. Following a set structure can help keep the conversation on track and make sure you’ve gone over everything. The facility you’re working at might have its own specific framework and set of questions they want you to ask. For example, Ob-Gyn medical assistants would need to ask questions about sexual history, contraception use and certain symptoms that other medical assistants may not normally have to address.

Generally speaking, most patient history conversations are as follows:

  1. Greet the patient by name and introduce yourself
  2. Ask, “What brings you in today?” and get information about the presenting complaint
  3. Collect past medical and surgical history, including any allergies and any medications they’re currently taking
  4. Ask the patient about their family history
  5. Ask questions about their social history and lifestyle, like what they do for a living and any smoking or alcohol habits
  6. Wrap up by seeing if they have any questions for you, thanking them for their time and then letting them know the doctor will be with them shortly

Interacting with Patients

Patient history should always feel more like a conversation rather than an interrogation. It’s important to establish trust, respect and honesty so that they feel relaxed and comfortable. You can do this through little gestures like making small talk and asking what their preferred name is. Not only does this benefit the doctor-patient relationship, but it can also help calm the patient’s nerves. You don’t want them to feel anxious or excited, because that can affect certain readings, like blood pressure.

When discussing their medical history, especially in regards to potentially sensitive topics, it’s essential to remain neutral. If the patient feels judged or uncomfortable for any reason, he or she might hold back and you won’t be able to get as accurate and detailed notes as possible. Practice active, empathic listening to show him or her that you care and understand. Also, always remember to avoid using medical terms that might cause confusion.

Ensuring Accuracy

By the time you’re done taking the patient’s history, your record should be detailed and complete. Here are some techniques you can use to improve accuracy.

  • Don’t interrupt the patient while they’re speaking
  • Prompt them by offering specific examples of diseases, conditions or medications in case they might be forgetting something
  • Conduct a systems review around the presenting complaint to make sure any associated symptoms are accounted for
  • Repeat their answers back to them
  • Get to know them, their lifestyle and their daily routine to get a better understanding of the big picture and if there have been any significant events in their life recently
  • If you’re confused or unsure how to work the EMR (electronic medical record) system, always ask a coworker for help

You’ve Got This

The Medical Assistant Program at Prism Career Institute teaches you everything you need to know about taking patient history. So when you walk into the exam room with your very first patient, you can feel confident in your knowledge and skills. To learn more about job opportunities for medical assistants, get in touch with Career Services today.