Chapter 32: The Medical History and Patient Screening

The patient’s main health concern is called:

the chief complaint.

The more intense form of screening that developed during wartime and involved the sorting and assessment of soldiers’ injuries is:

Triage

Beliefs and behaviors that tend to influence how we view others are:

Biases

Screening portion of the interview should end with this

Summary

Type of question that demands more than a yes or no answer.

Open-ended question

_______ describes what makes symptoms worse

Aggravating factors

_______ describes the area the symptom covers

Location of symptoms

______ describes when the symptoms started and what the patient was doing at the time

setting and timing

______ describes the characteristic of the symptom

Quality of the symptom

______ describes other minor symptoms in addition to the chief complaint

Associated symptoms

______ describes where the symptom is found

Location of the symptom

______ describes what makes the symptoms better

Alleviating factors

______ describes the pain associated with the symptom

severity

Information or symptoms that can be observed (that are perceptible to other people), such as swelling, bruising, vital signs, and physical examination findings

Objective

Calling patients by pet names or terms of endearment (e.g., Honey, Hon, and Dear) may be interpreted as:

patronizing

Medications, vitamins and herbal supplements, or home remedies are ______ medications

Over the counter (OTC)

The process of obtaining information from patients to determine who will be the most beneficial to handle their needs is called:

patient screening

The screening and interview commonly take place in the:

examination room or private room

The purpose of the screening is to help patients focus on their:

Chief complaint

When patients return for follow-up visits, the face-to-face screening should focus on determining:

How they have felt since the last office visit

The ____ decides what is done by the medical assistant during the in-person screening.

provider

When taking down a patient’s chief complaint, you should:

record it in the patient’s own words

When performing in-person screenings, you should ask patients if they are taking:

any type of medication, prescribed or otherwise

A ____ provides a pictorial breakdown of a patient’s family health history.

genogram

A review of symptoms (ROS) is an orderly and systematic check of each of the body systems is recorded and is performed by:

the provider

Never give a patient information that is:

beyond your scope of practice

Always question the patient about any allergies to drugs, including OTC and herbal supplements, food, or environmental factors because true allergic reactions can be very serious, even life-threatening. If the patient indicates he or she does not have any allergies you should enter _______ in the patients chart

"No known drug allergies" (NKDA)

True or False: The medical history is an essential part of patient care that helps guide diagnosis and treatment.

True

True or False: A patient’s medical history should only include information about their current medications

False; it should include past medical history, allergies, and other relevant health information.

True or False: It is unnecessary to document a patient’s allergies in their medical history

False; documenting allergies is crucial for patient safety.

True or False: Patients are encouraged to provide detailed information about their symptoms during the medical history process

True

True or False: The medical assistant should ask open-ended questions to encourage the patient to share their health concerns

True

True or False: Social history includes information about a patient’s lifestyle, such as smoking and alcohol use

True

True or False: A medical history should be updated only during the initial visit of the patient

False, it should be updated regularly to reflect any changes in the patient's health status.

True or False: The chief complaint is the primary reason a patient seeks medical care

True

True or False: Personal history in a medical history includes previous surgeries and hospitalizations

True

True or False: Cultural background can influence a patient’s health beliefs and practices

True

True or False: It is acceptable to make assumptions about a patient’s health based on their age and gender

False, as this can lead to stereotypes and overlooks individual health needs.

True or False: Medical assistants should be trained to recognize non-verbal cues that patients may exhibit during history-taking

True

True or False: It is important to maintain patient confidentiality when collecting and documenting medical histories

True

True or False: A patient’s immunization history is not relevant to their overall medical history.

False, as immunization history is essential for understanding a patient's health status and risk for disease.

A patient's ______ history includes information about diseases that run in their family

family

The ______ is a series of questions to assess different body systems and identify any symptoms the patient may have

Review of systems (ROS)

Medical assistants should use _______ questions to encourage patients to provide more detailed information about their health

open-ended

______ questions are helpful for obtaining specific details from the patient about their symptoms.

Closed-ended

Confidentiality is crucial when handling a patient’s medical history to maintain their _______.

Privacy

When documenting a patient’s history, medical assistants must be careful to avoid any ______ or assumptions about the patient's conditions

Bias