Patient Intake and Screenings

MA Clinical Setting 

• Consistent intake procedure to ensure patient safety and preparedness

• Vital signs are taken. (stress, food or liquid intake, medical conditions, age, and physical activity can affect vital signs)

• Maintain visual and physical contact with child patients until they return to their parent or guardian.

Identify Patient 

• Demographic information includes name, address, telephone number, insurance information, and emergency contact. 

• The most common method is to have patients state their full name and date of birth. 

Medical Billing

• a common form of identification is to ask for the patient’s full name and verify the last four digits of their SSN

• Name and birth date are the two most common identifiers used when face-to-face and receiving care.

Histories

All patients should have a minimum screening, including the chief complaint and medication review, at each visit.

Chief Complaint

• Also referred to as chief concern, is subjective information documented in the medical record in the patient’s own words. 

•  identifies the reason for the visit. “Please tell me why you are coming in today”

Medication reconciliation 

• Medication reconciliation is a formal process necessary at every office visit. 

• Comparing the patient’s list of medications to the medical record is a safety measure that reduces the risk of improperly prescribing an incorrect or contraindicated prescription, including medication interactions and adverse reactions.

Hypersensitivity

• Allergic

• Most electronic formats offer safety measures of alerting the provider if a prescribed prescription could cause a reaction.

•  In a paper chart, flag the patient’s allergy in several areas. It is often noted in red ink or using red allergy stickers.

Screening

When screening a patient, ask specific questions about their lifestyle. 

Mini-Mental State Exam, Anxiety and Depression Screening Tools

• The Patient Health Questionnaire-2 (PHQ-2) focuses on the patient’s frequency of depressed mood over two weeks. 

• If the patient’s answers reflect a positive response to depression, the medical assistant can proceed to the Patient Health Questionnaire-9 (PHQ-9). 

• Older adult patients could require a mini-mental examination to evaluate for dementia or other degenerative disorders.

Common Depression Symptoms

• Difficulty going to sleep, staying asleep, or getting up in the morning

• Profound sadness and fatigue

• Change in appetite​​​​​​​

• Loss of energy

Anxiety

• The GAD-7 questionnaire is for general anxiety and used to screen patients for anxiety.

• Panic