Ch 32 The Medial History and Patient Screening

Screening

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

Triage

The process of prioritizing the conditions of the injured following a disaster by separating them into groups according to seriousness.

Emergent conditions

Unexpected occurrences or situations demanding immediate action; these are always given highest priority.

Chief Complaint (CC)

The patient's main clinical concern or reason for the office visit; it should be written with precision and conciseness.

Subjective symptoms

Symptoms that are felt by the individual patient but are not perceptible or observable by others (e.g., pain, dizziness).

Objective symptoms

Signs and symptoms that can be observed, seen, or measured by others (e.g., swelling, a rash, vital signs).

History of Present Illness (HPI)

Detailed information about the chief complaint, including when the problem started, what makes it better or worse, and what actions the patient has taken.

Biases

Our beliefs and values that influence how we view others and can affect clinical observations.

Patronizing

Treating a patient condescendingly; a negative behavior that medical assistants must avoid.

Remedy

Anything that relieves or cures a disease.

Allergies

An abnormal reaction by the body to substances that are normally harmless; must always be documented explicitly (or noted as NKA).

NKA

No Known Allergies; the standard notation used in a medical record to indicate a patient has been asked and reports no allergies.

Genogram

A diagram or special history form of medical history, including at least three generations, that shows a provider a patient's chances of developing hereditary diseases.

Past History (PH / PMH)

A section of the medical history identifying all previous surgeries, health problems, illnesses, or disorders ever diagnosed.

Family Health History

A record of the health status, ages, and causes of death of immediate blood relatives used to identify genetic tendencies.

Social History

A section of the health history concerning the patient's lifestyle and personal habits (such as alcohol, tobacco, and drug use) that can impact overall health.

Review of Systems (ROS)

An orderly, systematic check of each body system performed by the provider during a physical examination.

Clinical Diagnosis

The conclusion arrived at by a provider using facts obtained through the medical history, physical exam, and laboratory testing.

Prioritizing

Arranging tasks or patient needs in order of importance; a crucial skill for managing duties in a medical office.

Over-the-Counter (OTC) meds

Accessible, nonprescription drugs, vitamins, and herbal supplements; these must always be documented due to potential drug interactions.

Name five areas of knowledge that you should have to provide good patient screening.

Medical terminology, anatomy and physiology, diseases and disorders, emergency procedures, and medications

If a patient complains of pain, what additional questions do you need to ask?

You need to identify the location, when it began, its characteristics, and its intensity; any other symptoms; things that make it better or worse; when the pain started; and what the patient was doing when it started

Why might a health history form not be filled out entirely by the patient?

The patient may have a language or a reading problem or may not be able to write or understand the information being asked.

What is the goal of patient screening?

To determine why the patient is seeking health care, what the main problem is, and any other concerns. It will also seek to find out whether the patient has done anything about the problem thus far.

Why should you ask a patient whether he or she has any allergies, and how should you note it in the patient’s medical record?

A true allergy can cause severe and even life-threatening reactions. Always record the specific allergy—or write “no known allergies” (“NKA”) if the patient has none—to indicate having asked the question and the patient’s response

After obtaining a patient’s chief complaint, the medical assistant should do what next?

Summarize the information with the patient for clarification and to see whether anything is missing, get the patient’s approval, and sign the form.