Medical assistants regularly conduct the patient interview, and take and record both new and established patient health histories. They may conduct certain components of the physical examination to support physicians. It is important that you be organized in your approach to patient interviews. You will need to use all of your listening and observation skills to accurately and thoroughly gather patient information during the interview. You must become proficient in documenting your findings and observations in the patient’s medical record. In this section, you will review the basic structure and elements included in a patient interview. Follow all policies and format requirements that are unique to your practice setting. Many offices have standard forms or formats for patient interviews that may be manual or computer based. You will need to adapt the general interview strategies to your work setting.
If this interview is the patient’s first visit to your office, make sure you offer a greeting and explain your role and functions as a medical assistant. Let the patient know what to expect during the interview and health examination and approximately how long the process may take. It would be a good idea to discuss this and any laboratory tests or procedures that are generally included in the first visit on the phone before the visit is conducted. Patients can help by bringing in information such as health records or medication records to the appointment.
Make sure that the examination room is clean and comfortable and that all equipment and supplies that you or the provider may need are assembled and prepared for use. Make sure that the patient needs for privacy are protected during the interview. Arrange for any accommodation that the patient may need for an effective two-way communication. You will want to have a gown, draping cloths, and examination gloves handy. In some practices, a health history form is sent to the patients in advance so they can self-record their family health history, personal health history, and complete a review of body systems or signs and symptoms that they are currently experiencing or have experienced. Some forms contain questions regarding lifestyle and behaviors such as smoking, drinking, and use of medications. If the form has been brought in to the visit, it is important to review it completely with the patient and validate any significant items or concerns noted in the self-report. If your office does not provide this self-report, you will want to obtain a health history as part of the interview. See Chapter 12 for information on the standard components of a health history.
Health information is recorded in the patient’s medical record along with pertinent quotes from the patient when possible. After the interview, you will review the information with the patient and instruct him to change into a gown for a physical examination. You may be participating in the exam by taking the patient’s vital signs. If you are examining a child, you will want to record the height and weight on a growth chart. For infants up to one year of age, you will also record the head circumference.
For routine office visits or follow-up appointments, your interview should begin with the patient’s chief complaint, history of present illness, and any updates to the past medical history since her last appointment. Many offices use a problem-oriented medical record that allows the physician, nurses, and medical assistants to document subsequent treatment into the categories of health problems and health interventions noted in the patient problem list.