Patient Intake and Screenings

Patient Intake and Screenings Campbell Palmer RN MA

Clinical Setting A medical assistant who works in the clinical area of the office must complete several activities prior to the provider examining the patient. Although patient encounters are individualized, the medical assistant follows a consistent intake procedure to ensure patient safety and preparedness for the encounter. MA Clinical Setting Vital signs are taken during each intake process and serve as key indicators of homeostasis. Alterations in values could indicate a precursor of illness or disease. Factors such as stress, food or liquid intake, medical conditions, age, and physical activity can affect vital signs. It is extremely important to be accurate in obtaining vital signs as well as have knowledge of normal and abnormal values to effectively communicate with the provider and deliver education to patients. MA Clinical Setting The importance of safety in the ambulatory care setting cannot be underestimated. Make every effort to maximize the safety of patients and staff to prevent injury and avoid litigation. Planning for environmental emergencies, such as fires and natural disasters, is essential to protect human life. This involves identifying emergency policies and evacuation plans and having emergency equipment easily accessible. MA Clinical Setting In an emergency, pay particular attention to the safety of children, older adults, and patients requiring accommodations. Children are prone to falls and injuries involving sharp objects, choking on small items, or touching electrical outlets. When preparing the patient prior to being seen by the provider, take precautions to avoid a child falling from the examination table. Maintain visual and physical contact with patients until they return to their parent or guardian. MA Clinical Setting Safety Patients may need assistance walking or getting onto an examination table. Some patients might also need supervision while waiting to be seen. Restrooms should be equipped with handrails and emergency alert buttons; if they are not available and there is a safety concern, someone should be with or near the patient. For all patients, be alert for potential hazards and take measures to maximize patient safety. Identify Patient A patient’s medical record contains demographics that require verification at each visit. Demographic information includes name, address, telephone number, insurance information, and emergency contact. Each established patient has a medical record. Some electronic medical record systems identify patients by an assigned medical record number, making each patient unique within the health care system. Patient Identification The first step in ensuring safety is proper patient identification. The Joint Commission stresses the need to use two methods of identification to validate that care and treatment are delivered to the correct patient. The most common method is to have patients state their full name and date of birth. Avoid saying the patient’s name and then asking them to confirm it. A patient could respond to the wrong name, especially in a time of crisis, stress, or illness. Medical Billing When dealing with financial issues, such as billing, a common form of identification is to ask for the patient’s full name and verify the last four digits of their Social Security number. Rarely does anyone ask for the full Social Security number due to issues related to confidentiality. Name and birth date are the two most common identifiers used when face-to-face and receiving care. Histories The patient screening process can also be referred to as rooming patients. It is the process of gathering initial information from the patient. Depending on the type of visit, the amount of information collected during the screening process varies, but all patients should have a minimum screening, including the chief complaint and medication review, at each visit. Subject Information A chief complaint, also referred to as chief concern, is subjective information documented in the medical record in the patient’s own words. This is likely the first piece of information the medical assistant records that identifies the reason for the visit. “Please tell me why you are coming in today” and “What brings you to the office today?” are open-ended questions that elicit the chief complaint. The patient’s response of “My stomach hurts” would be subjective information. When recording a patient’s chief complaint, use quotation marks when indicating anything directly stated by the patient. Subjective information is usually described and experienced by the patient and is not measurable. Medications Routinely ask patients to bring all medications or a current list of medications to the office for appointments. This helps the MA compare medications being taken to those in the medical record and ensures patients follow the correct instructions. 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 Patients can develop an allergy at any time. Educate the patient on identifying any unusual reactions when starting a new medication. Ask what allergies the patient has and what type of reaction occurred. For example, gastrointestinal upset, previous anaphylactic reactions, or hives, as this will help the provider determine if an allergic reaction is likely to occur in the future. Document the allergy status in the medical record. Avoid exposing a patient to a substance that can lead to an allergic reaction or life-threatening anaphylaxis. 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. Objective Information A personal and family history is completed at or prior to the first office visit. This document contains information reported by the patient as a starting point for the provider collecting the patient’s objective information. Objective information is observed or can be measured. A patient’s past medical history is objective information because it is documented and measured within their health record. When a patient completes a health history form, the MA will ensure that it is complete and answer any patient questions. This documentation identifies any predispositions to diseases and conditions and forms an overall picture of the patient’s health based on past events. Although this extensive history is usually only completed once, routinely review it when a patient attends appointments and determine whether changes or updates need to be included. Many clinics request that patients update their medical history forms annually. Health Record Information Section The sections of the health record include the following. Administrative section Patient information/demographics Financial and insurance information Correspondence Clinical section Past medical history/family history/social history/occupational employment Medical history: past illnesses, surgeries Family history: illnesses or diseases relevant to the immediate family Social history: diet, exercise, caffeine intake, smoking, use of alcohol or recreational drugs Occupational history: any occupational employment hazard or exposures Orders/referrals Clinical data Progress notes Diagnostic imagining information Laboratory information ​​​​​​​Medication list/allergies Tobacco, HIV, Alcohol Screening When screening a patient, ask specific questions about their lifestyle. The patient’s responses can trigger the need for a wellness screening or assessment. Increased data collection requirements focus on prevention and quality patient care. Patients will be interviewed regarding their use of alcohol, tobacco, caffeine, recreational drugs or other chemical substances, and sexual practices. Also, question the patient about their occupational history to identify any hazards to which they may have been exposed during their employment, such as asbestos. Various types of machinery could pose a potential risk of injury and impact their health status. In addition, ask the patient about diet and exercise to provide greater detail regarding their health status. Be aware that the patient may not be comfortable answering these questions or even refuse to answer some of these questions. Attempt to ask the questions again or document “patient declined to answer” in the patient’s medical record. Mental health screenings assess the patient’s safety and mental status. Depression screening asks questions about the patient’s moods, thoughts, and feelings. 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). This screening asks additional questions to assess if the patient meets the criteria for a depressive disorder diagnosis. Older adult patients could require a mini-mental examination to evaluate for dementia or other degenerative disorders. Depression can be difficult to recognize. Therefore, one must know the common symptoms. Mini-Mental State Exam, Anxiety and Depression Screening Tools 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 Anxiety is a common emotional response for many people. Anxiety can be a response to fear or an unfamiliar situation. For example, some patients have “white coat syndrome," which is anxiety related to seeing a health care provider for an evaluation. Anxiety can vary from mild to severe symptoms. The GAD-7 questionnaire is for general anxiety and used to screen patients for anxiety. Common Anxiety Symptoms Heightened ability to observe or make connections Difficulty focusing on details A sense of panic Irritability Feeling cold, sweaty Heart palpitations​​​​​​​ Shortness of breath