As a medical assistant, you will likely be asked to take medical histories. A medical history is a record of a patient's condition, past and present. It files:.
Physical or mental conditions of which the client understands.
Significant health problems the client might have suffered.
Surgeries the patient could have undergone.
A case history also contains as much information as you can get about any pain, pain or various other medical problems the patient could be experiencing.
Getting precise medical histories is vitally important to a physician's capability to provide proper care. An excellent history can assist speed the diagnosis of a present complaint. It can point the way to proper therapy. And it can inform a doctor to prevent medications that might cause more harm than great (such as when a client dislikes a household of drugs).
So how do you take a medical history? It is normally through an individualized exclusive meeting with the client. Right here are the fundamental actions:.
1. Introduction. Begin by introducing yourself and discussing you are helping the doctor by taking a medical history. Be as friendly and open with the patient as you can to establish relationship and develop trust. It is necessary the patient feels comfy with you because you should get complete, truthful responses.
2. Standard Personal Information. Confirm the client's name, address, telephone number and emergency contact.
3. Present Complaint. Is the patient here today to deal with a certain grievance or simply to get a routine health examination? If the client has a current complaint, you need to get a full description of the problem.
Questions to ask consist of:
Where is the problem located?
What are the general symptoms?
When did this problem begin?
Has it changed over time?
Does it affect any other areas of the body?
Does it vary depending on time of day?
Does anything make the symptoms better or worse?
Does the problem interfere with daily activities or sleep?
4. Current/Past Illnesses and Conditions. Part of any medical history is a record of any significant health problems or conditions from which the client presently suffers, or which the patient has had previously. Ask about any current conditions that have actually been detected, including:
Hypertension (high blood pressure)
If the patient is female, is she pregnant?
Ask about childhood illnesses, including:
Rubella (German measles)
Likewise verify all immunizations the client has had, consisting of vaccines for polio, tuberculosis and DTP (diphtheria, tetanus and pertussis), as well as the youth conditions provided above.
5. Surgeries and Procedures. Get the when's and why's about any previous surgical treatments or various other major medical procedures. Were they effective? Existed any problems? If the client is over 50, did he/she ever have a colonoscopy?
6. Obstetrics. If your client is female, you need to ask:.
Has she had any previous pregnancies? If so, how many?
Has she ever suffered any miscarriages?
Were there any problems during pregnancy, such as hypertension, toxanemia (pre-eclampsia) or diabetes?
Were the shipment typical, or were C-sections required? If so, why?
Has the client ever had an abortion? If so, was it optional or for medical reasons?
7. Current Symptoms. Although the patient might have a particular complaint-- or no problem at all-- you still wish to look for indications of other conditions that could be contributing to the trouble.
Ask the patient if he/she is experiencing:
Shortness of breath
Loss of appetite
Recent changes in bowel habits
Blood in the stool
Pain or burning while passing urine
For guys, you should ask about the presence of any penile discharge or issues with sexual functions.
For women, ask about the presence of any vaginal discharges and regularity of menstrual cycles. If the patient is currently undergoing menopause, when did she experience her last period?
8. Prescribed Medications. Ask the patient to provide all prescription medications he/she is presently taking.
9. Lifestyle. Numerous of our way of life selections directly-- or indirectly-- add to our wellness.
You for that reason wish to ask your patient about:
Average hours of sleep daily
Tobacco use (now or in the past)
Alcohol use (what and how often)
Regular exercise (what and how often)
Travels abroad (where and when)
Recreational drug use (what and how often)
10. Family tree. Because lots of diseases and conditions run in families, ask the client about:.
Moms and dads-- alive or dead? If dead, how?
Brother or sisters-- alive or dead? If dead, exactly how?
Any genetic diseases understood to be present in the family line.
Conclude by asking the patient if there are other concerns or concerns that you must note.
The order where you ask these questions will likely be determined by the physician for whom you work. You will most likely be given a form with these-- or similar-- concerns in their favored order.