Eighty-three percent of adults have had some contact with a health care professional in the past year. Fifty-two percent of those visits were with their primary care physician, according to the Centers for Disease Control and Prevention (CDC). The most frequent reason for patients to visit their primary care physicians is to receive and ask questions about medication.
That means that 48 percent of people did not see their primary care physicians last year. The mind-set of patients should be to see their physicians before there’s a problem, before they become ill. It is important for physicians to set a baseline when the patient is healthy. This is what the initial patient medical interview questions are for and why a patient’s medical history is compiled.
Whether the medical assistant uses a list of questions or a preprinted form, patients will provide their medical history prior to treatment. This includes elements of the patient’s health history, questions about any medications the patient is currently taking, any surgeries that have been previously performed, and whether family members have any medical issues that may be hereditary. The interview questions also include social habits, like alcohol intake and smoking, personal exercise regimens, and eating habits.
After the initial interview questions are answered, the medical assistant will proceed to check vital signs and set a baseline for future visits. Vitals will be included in the patient’s medical history. These include height, weight, age, blood pressure, respiration rate, pulse rate, and temperature. As these vitals change, the physician can better understand what symptoms may mean in a patient who is ill.
What Is a Medical History?
A medical history is a record containing information about a patient’s past and present health status. These interview questions confirm all hereditary health issues and the patient’s personal habits.
What Are the Elements of a Medical History Interview?
A medical history interview typically includes identifying data, past history, review of systems, family history, and social history.
- Identifying Data – This includes most demographic information and answers to questions used for administrative purposes, including the patient’s name, address, phone number, Social Security number, employer information, insurance carrier information, health care policy number, marital status, gender, and race.
- Past History – This is the patient’s past health status and assists the physician in assessing patients and treating their illnesses. The past history interview information includes allergies, immunizations, childhood diseases, vaccinations, surgeries, injuries to the body, previous illnesses, current and past medications (including over-the-counter medicines), vitamins, and oral contraceptives.
- Review of Systems – The patient’s medical history interview form lists known symptoms and illnesses associated with each body system that the patient may forget to mention. The systems include the cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, endocrine system, hematologic system, and neurologic system.
- Family History – Family history includes the health status of siblings, parents, and grandparents. Many diseases are hereditary and are passed down from parent to offspring. Other diseases are familial and tend to occur often in a particular family. Both information about hereditary and familial histories will help the physician better treat the patient’s illness. If a parent is deceased, the medical assistant will want to note the age and cause of death.
- Social History – This is the patient’s lifestyle, including marital status, current and past jobs, education, the patient’s diet, use of alcohol and tobacco, accommodations, living arrangements, support system, pets, hobbies, and sexual history. This information can be used by the medical assistant to educate the patient and prevent future illnesses and diseases.
Conducting the Patient’s Medical Interview
Before the first visit and every few years thereafter, the medical assistant will want to gather a medical history to properly conduct a patient’s medical interview at the beginning of each visit. By keeping an accurate account of the medical history and habits of the patient, the physician can better treat the patient when ill.
Before conducting a patient’s medical interview, the medical assistant will want to become familiar with the medical history form. At the beginning of a patient’s medical interview, the medical assistant will introduce himself/herself properly as a medical assistant. This way the patient understands the medical assistant’s credentials and is not misled.
While conducting the patient’s medical interview, the medical assistant will identify any barriers to communication. These barriers may include a hearing impairment or unfamiliarity with the English language. The medical assistant should avoid using technical medical terminology and maintain eye contact with the patient to build rapport.
The medical assistant inventories all signs and symptoms, both from the patient and as identified during the vital signs assessment. What is the patient explaining as symptoms, and what does the medical assistant identify as signs of illness? The medical assistant notes whether the problem is acute or chronic.
Finally, the medical assistant wants to understand why patients are visiting the physician’s office and what illnesses or questions they may have. It is important for the medical assistant to question what led up to the illness for better understanding of the cause. The medical assistant should also ask if the patient is taking any over-the-counter or homeopathic medicines that may not be included in the current medication list.
A good way for a medical assistant to document a complaint is to identify a chronologic timeline leading up to the illness. Then, the medical assistant should identify the location of the pain on the patient’s body. The medical assistant identifies the severity of the pain, any self-treatment for the pain, and how the treatment affected the pain. The medical assistant also makes note of how long the patient has had symptoms.
HIPAA
All the information compiled in the patient’s medical history and medical interview is confidential and protected by the Health Insurance Portability and Accountability Act (HIPAA). Only those directly involved in the patient’s care, and the patients themselves, can access the patient’s medical history.
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