Patient History Interview

After the patient’s vital signs have been taken and accurately recorded, you may be expected to obtain a patient health history. This will be done in detail at the first visit and then reviewed and updated with every subsequent visit. The process may start prior to the first visit with a brief telephone history when the initial appointment is scheduled. The gathering of information should be done in a comfortable and private setting. Recording of the information should be complete and not reflect any opinion or interpretation by the medical assistant.

Components of the Medical History

• Personal data: You must make sure that you have the correct name, address, telephone number, date of birth, and insurance information. This should be reviewed at every visit. Other parts of the personal database may include the initial physical, lab work, and medication list for the patient. The medication list should also be checked and updated with every visit and in the event that the patient calls into the office with a question or a request for the physician.
• Chief complaint: This is the patient’s reason for seeking medical care in her own words. This should contain onset of symptoms, a description of any pain or discomfort, what type of treatment the patient has tried at home, what the patient’s opinion of the problem is, and any other medical treatment that has been sought for this problem.
• Past medical history: This would include immunization, childhood illnesses, allergies, accidents, surgeries, past hospitalizations, and any major illnesses.
• Family history: Here information about the immediate family members and their state of health or cause of death would be recorded. Information about genetic or familial diseases would be placed in this section.
• Social history: This section would include information about employment; education; lifestyle choices; diet and exercise; use of alcohol, tobacco, or drugs; and sleep habits. This information can help the care provider to assist the patient in making changes in this area to increase wellness and prevent disease.
• Systems review: This is the area where the present illness is discussed and charted. It is a head-to-toe systemic assessment that looks at all aspects of the patient. By reviewing all body systems, the provider may discover valuable clues that the patient did not think were relevant to the current situation. This may also uncover early signs of problems that can be addressed before they become problematic for the patient.

All areas of the medical history should be documented carefully in the patient chart. Care should be taken to use correct accepted medical terminology and only approved abbreviations when documenting in the chart. Unclear or unapproved abbreviations can lead to problems with communication between health care workers. All entries must be signed and legible.

Patient education and teaching also must be documented in the chart. There should be notations about the patient response to education and teaching so follow-up can be continued on subsequent visits. Referrals to other agencies or support services for follow-up should be documented.