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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5519_Библиотеки_им_академика_М_И_Перельмана.pdf
Medical History and
16
Patient Assessment
Chapter Objectives
● List the typical information included on a medical
history form.
● Explain the use of different techniques used to
collect information during a patient interview.
● Explain how to use open-ended and closed-ended
questions during a patient interview to obtain
information.
● Perform patient screening via telephone and face to
face.
● Explain the difference between patient signs and
symptoms.
● Explain the difference between a chief complaint
and present illness.
● Summarize how to measure and record a patient’s
height and weight.
● Explain the differences in taking a patient’s
temperature using the oral, rectal, axillary, and
tympanic methods.
● Explain how the body controls temperature and the
factors that inuence it.
● Describe how to assess and record a patient’s
respiration.
● Identify body sites used for palpating a pulse.
● Explain how to choose the correct blood pressure
cuff size.
● Describe the ve phases of Korotkoff sounds.
● Identify the factors that may affect blood pressure.
● Accurately obtain and record vital signs including
blood pressure, pulse, temperature, respiration, and
pulse oximetry.
CAAHEP & ABHES Competencies
CAAHEP
● Obtain vital signs.
● Apply critical thinking skills in performing patient
assessment and care.
● Use language/verbal skills that enable patients’
understanding.
● Demonstrate respect for diversity in approaching
patients and families.
● Differentiate between subjective and objective
information.
ABHES
● Gather and process documents.
● Obtain vital signs, obtain patient history, and
formulate chief complaint.
301
302 Section IV Clinical Medical Assistant Skills
Chapter Terms
Afebrile
Anthropometric
Assessment
Diagnosis
Familial disorder
Febrile
Hereditary disorders
Homeopathic
Abbreviations
BP
CC
FH
Case Study
Robert Foster is a new patient recently seen by Dr.
Kauffman in the emergency room for abdominal
pain and now has arrived at the physician’s ofce
for a follow-up appointment. MaryAnn Hastings,
Dr. Kauffman’s medical assistant, provided a new
patient history form for Mr. Foster to complete. He
Ht
P
PH
Hyperpyrexia
Metabolism
Paraphrasing
Pyrexia
PI
R
ROS
tries to complete the form but does not understand
some of the terms used on the form. He is embarrassed to ask the medical assistant for help so he
leaves those areas blank. When he gives the form
to MaryAnn, she notices that he has not completed
all the required elds on the form.
Reecting
Signs
Sphygmomanometer
Symptoms
T
Wt
It is imperative that a physician knows a patient’s past
and current health information in order to diagnose and
treat the patient’s present illness. The physician will try
to establish a diagnosis, the process of identifying a
disease or illness. As a medical assistant, you play a large
role in collecting the information the physician needs for
a medical history and assessment.
The patient’s medical history is information about the
patient’s past and present health status. It also includes
information about the health of family members and information about the patient’s social habits, such as smoking
and alcohol use. The patient’s family should include only
those members who are biologically related to the patient.
Assessment is the process of gathering information in
order to determine the patient’s problem. It begins with
asking standard questions and recording the patient’s
answers. The methods used will be outlined in the ofce
policy and procedure manual.
C
O
G
It is the medical assistant’s responsibility to work initially with the patient to gather the medical history
information. An example of a typical history form, front
and back, is shown in Figure 16-1.
THE MEDICAL HISTORY
The following are the methods used by most ofces
to collect and record the patient’s medical history.
The patient completes a form upon arrival for their
r
rst visit, before seeing the physician.
The patient returns a form that was mailed to them
r
prior to their rst appointment.
The patient completes an electronic form online prior
r
to their rst visit.
The medical assistant interviews the patient using a
r
medical history form with a list of questions.
The physician completes the medical history form
r
during the patient’s examination.
It is important for the medical assistant to know and
understand all aspects of the medical history forms used
in the medical practice. When the patient has completed
their portion of the medical history form, the medical
assistant should review the form to make sure the patient
did not leave any areas blank and that the information
provided by the patient is understandable.
Medical History Information
Medical history forms may be differently formatted,
but the information required is typically the same for
all of them. There may be additional questions asked
Chapter 16 Medical History and Patient Assessment 303
Figure 16-1 A sample medical history form, front and back. (Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
304 Section IV Clinical Medical Assistant Skills
Figure 16-1 (continued )
Chapter 16 Medical History and Patient Assessment 305
on medical history forms used in specialty practices.
Common information included on standard medical
history forms includes the following:
Demographic data
r
Past history (PH)
r
Review of systems (ROS)
r
Family history (FH)
r
Social history
r
Demographic Data
Demographic data are the patient’s identifying information.
Most of this information is required for the practice’s business operations. In addition to the patient’s name, mailing
address, and phone number, it also includes the following:
The patient’s emergency contact information
r
The patient’s gender, marital status, and race
r
The patient’s Social Security number
r
The name, address, and phone number of the patient’s
r
employer
The name, address, and phone number of the patient’s
r
insurance carrier
The patient’s health insurance policy number
r
Past History
The past history (PH) refers to any information about
the patient’s past health status. This helps the physician
plan the patient’s current care. The past history includes
information about the patient’s:
Allergies
r
Immunizations
r
Childhood diseases
r
Current and past prescribed medications
r
Over-the-counter medications and herbal supplements
r
Prior illnesses
r
Prior surgeries
r
Prior hospitalizations
r
Prior accidents
r
of each body system. Information may be revealed that
a patient may have forgotten to note in the PH section
or thought was unimportant. The questions are usually
in a sequence from head to toe.
Family History
This section of the medical history form asks for information about the health of the patient’s biological relatives.
Some diseases or disorders have familial or hereditary
links. A
ally common within a family. Hereditary disorders are
passed from parents to their offspring. In the family history (FH) section, health information is gathered about
the patient’s parents, brothers, sisters, and grandparents.
If any immediate family member is deceased, the cause
of death should be noted in the patient’s medical history.
familial disorder is a problem that is unusu-
Social History
The social history section covers the patient’s lifestyle. It
includes information about marital status, occupation,
education, and hobbies. It may also include information
about:
Diet
r
Tobacco use
r
Alcohol use
r
Sexual history
r
Sleeping habits
r
Exercise
r
The social history information helps the physician
understand how the patient’s illness and any treatment
may affect the patient’s lifestyle. It also helps the physician see how the patient’s lifestyle and illness may be
related.
This information also can be a guide to the need for
patient education. The physician may want to address
some patient behaviors in order to avoid future medical
problems. For example, high tobacco use or a diet high
in fat may lead to illness or disease.
Case Question
A
F
F
doesn’t understand some of the medical terms
used on the form and is unsure how he should
answer. How can MaryAnn help him feel more
comfortable and assist him in providing the necessary information to complete the form?
When MaryAnn, the medical assistant,
asks Mr. Foster about the blank areas
of the medical form, Mr. Foster says he
Review of Systems
The review of systems (ROS) section contains questions
about overall health and specic symptoms or diseases
Interviewing Patients
To complete the medical history, the medical assistant
needs to interview the patient. Figure 16-2 shows a medical assistant with a patient she is interviewing. You can
see the medical assistant is maintaining good eye contact
with the patient.
The goal is to obtain accurate and relevant information. Throughout the interview process, the medical assistant is required to treat the information in a
patient’s medical history as condential. The Health
Insurance Portability and Accountability Act (HIPAA)
is a federal law that protects the privacy of health information. To comply with HIPAA, patient records must
be stored in a secure place. Electronic records need to be
306 Section IV Clinical Medical Assistant Skills
Figure 16-2 Conduct the patient interview in a private
ofce or exam room. (Reprinted from Kronenberger J,
Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
understood you correctly…” and then give a summary
of what the patient told you.
Allowing Silence
Allowing silence, or a pause, can be helpful during a
conversation. It gives the patient a chance to think about
what to say next.
Active Listening
Throughout the interview process, the medical assistant
will utilize active listening skills to show that you are
interested in what the patient is saying. Active listening
can be shown through words (verbal) or body language
(nonverbal).
Verbal. Show you are listening by occasionally using
encouraging words or sounds such as “yes,” “mm-hmm,”
or “ah.”
protected with password protection and limited access
by authorized individuals. The patient may give specic
permission for persons involved in the patient’s care to
access the record.
Interview Communication
The medical assistant must collect accurate and useful
information during the interview. A number of interviewing skills help with this process.
Reecting
Reecting is repeating back what the patient said, using
open-ended statements. For example, you might say,
“So, you were saying your heartburn is bad when…”
Paraphrasing
Paraphrasing means rephrasing what the patient said
in your own words. For example, you might say, “It
sounds as if you’re saying you have had heartburn and
sour stomach for the past week.”
Asking for Examples
Asking the patient for an example allows you to clarify
what the patient told you. For example, you might say,
“Can you describe exactly the pain from the heartburn?”
Asking Questions
Asking questions can help you get more information or
details about what the patient has said. For example,
you might ask, “Does the heartburn seem to happen
after eating certain meals or at a particular time of day?”
Summarizing
Summarizing, or recapping, the main points of what
the patient said helps to make sure you understood the
patient. For example, you might say, “Let me see if Ihave
Nonverbal. Your body language shows you are listen-
ing when you nod your head, smile, or make frequent
eye contact with the patient.
Case Question
A
F
F
time in the physician’s ofce as a follow-up. In
order to obtain the most complete information
about his condition, what questions should the
medical assistant ask him?
Mr. Foster was seen in the emergency
room for abdominal pain a few days
ago and is now being seen for the rst
Before the Interview
In order for the patient to feel comfortable and relaxed
during the interview, there are steps to take prior to
meeting. Here are two items that need to be planned
prior to the interview:
Be prepared. Make sure you’re familiar with the med-
r
ical history form and any previous medical history
provided by the patient. New patients will have lled
out a new patient questionnaire. For an established
patient, review and update the chart with any new
information.
Find the right location. To keep patient information
r
condential, a private area is necessary to conduct the
interview. Avoid public areas such as the reception
area where others might hear the patient’s answers.
A good location might be a private ofce or examination room. Besides ensuring privacy, you will be
avoiding distractions and interruptions. Interview
the patient alone unless he wishes family members to
bepresent.
Chapter 16 Medical History and Patient Assessment 307
Begin the Interview
At the beginning of the interview, put the patient at ease.
Begin every patient interview by identifying your name
and title. Make sure to mention your credentials when
talking to patients so they don’t get the false impression
that you are a nurse or physician. Explain the purpose
of the interview and how long it will take. Also tell the
patient that all information will be kept condential.
For example, you might say something like this:
“Good morning, Mr. Foster. My name is MaryAnn, and I
am Dr. Kauffman’s medical assistant. I would like to ask
you a few questions that will take about 15 minutes and
help the doctor diagnose and treat you. Please be assured
that all your responses will be kept in strict condence.”
First Impressions
You may be the rst person in the medical ofce the
patient sees or talks with. The impression you make is
critical to the patient’s overall opinion of the medical
practice. The words and manners you use should communicate respect as well as concern for the patient. This
professional but caring attitude will help you gain the
patient’s condence. Some patients may not share information until that feeling of trust has been established.
Communication Barriers
Sometimes, patients may have difculty expressing
themselves. You also may have a hard time understanding a patient. As you speak to patients, assess whether
there are any barriers to communication—things that
will get in the way of each of you understanding the
other. Here are some common communication barriers.
The patient has difculty speaking, reading, or
r
understanding English.
The patient has impaired vision or hearing.
r
The patient has a mental or psychological limitation.
r
There are several ways to help patients understand
what you are saying. You can help keep communication
owing by:
Avoiding highly technical or medical terminology
r
Paying attention to the patient’s nonverbal behavior
r
Adjusting your questions to suit the situation
r
Maintaining good eye contact
r
Having a family member or caregiver accompany the
r
patient
Assessing the Patient
During the patient interview, listen carefully as the
patient describes his medical problems. Pay attention to
the signs and symptoms, as well as the patient’s behavior.
Signs are objective information. That means they
r
can be observed or seen by someone other than the
patient. Some examples of signs are rash, bleeding,
or coughing. Other signs may be found during the
physician’s examination.
Symptoms are subjective information. They reect
r
changes in the body sensed by the patient. Symptoms
are not usually evident to anyone other than the
patient. Examples include patient complaints such as
headache, leg pain, nausea, or dizziness.
Acknowledge the patient’s feelings using techniques
r
such as reecting or paraphrasing. Saying something
like, “I understand that makes you feel worried,” will
reassure the patient that you’re attentive to his concerns.
Respond with facts, rather than reacting with emo-
r
tions. You may feel impatient with a patient’s questions or behavior, but the patient needs you to be both
professional and calm.
Sometimes, signs may indicate patient symptoms.
Afacial expression, such as wincing, may be a sign that
a patient is in pain. If the patient is holding onto furniture or walls while walking, it could be a sign that the
patient is feeling dizzy.
Making Observations
A good interview involves observation. This means
noticing things about the patient’s appearance or behavior. When you write your observations in the patient’s
medical record, make sure you include only what you
saw and heard. You should not record any judgments,
opinions, or conclusions you might have made about
what you observed. For example, you would not write
that someone must have hit the patient because there
were signs of bruising. Avoid making these assumptions.
Some examples of observations you might make of
physical and mental status information are as follows:
Pale or ushed skin
r
Visible bruises or injuries
r
Lethargy or tiredness
r
Crying
r
Confusion
r
Chief Complaint and Present Illness
After recording the patient’s medical history, you need
to nd out why the patient has come to see the physician. To do this, you must determine the patient’s chief
complaint (CC) and present illness (PI).
The chief complaint is the reason the patient is visit-
r
ing the doctor. It’s one statement describing the signs
and symptoms that led the patient to seek medical
care—for example, “I’ve had a headache for the past
3 days.” The chief complaint is recorded for every
visit, even if it is for a checkup or annual exam.
The present illness is a more specic account of the
r
chief complaint. It includes an order of events, such
as when the symptoms began, and any remedies the
patient may have tried prior to the appointment.
308 Section IV Clinical Medical Assistant Skills
Determining the Chief Complaint
Prior to the interview, review the patient’s medical history form to become familiar with the patient and help
you get complete information.
Asking open-ended questions usually will lead the
patient to reveal a chief complaint. Open-ended questions are those that encourage the patient to respond
with more than one or two words. Some examples are,
“What’s the reason for your visit today?” or “Can you
describe what’s been going on?” Make sure you maintain
eye contact so the patient knows you’re listening actively.
Closed-ended questions most often require only a yes
or no answer. These types of questions will not provide
many details about the patient’s condition. For example,
“Do you have pain?” doesn’t provide much information. However, you can use closed-ended questions to
get specic information about the present illness, such
as, “When did the pain rst start?”
You should document the chief complaint (CC) on
the progress report form in the patient’s record. Use the
patient’s own words in quotation marks whenever you
can. Make sure the progress report includes the date,
time of day, and your signature and credentials.
Detailing the Present Illness
Once you have recorded the patient’s chief complaint,
you need to get more details about the patient’s present illness (PI). It is important to establish the chain of
events associated with the illness.
For example, you must nd out if the patient has
tried any over-the-counter medications. These are medications that do not require a prescription. They include
aspirin, decongestants, antihistamines, and many others.
They also include vitamins, natural drugs such as herbs,
and some homeopathic medications.
Homeopathic medications are tiny doses of sub-
stances that would, in normal doses, produce the symptoms of the disease being treated. For example, Allium
cepa, which is made from onions, is a homeopathic
remedy for a cold. It is used because onions make your
nose run and eyes water when you cut them, just like a
cold does. In order to get more information about the
patient’s present illness, these are some questions that
you can ask:
Chronology—How and when did this problem rst
r
begin?
Location—Can you explain or show me where the
r
pain or problem is?
Severity—Can you describe the pain? Is the pain constant?
r
When did the pain rst begin? Are there times or movements that make the pain occur? Some medical ofces
have patients rate the severity of the pain on a scale of
1 to 10, with ten being the worst pain they can imagine.
Self-treatment—What medications (both prescrip-
r
tions and over the counter) and herbs have you taken?
Have they helped?
Quality—Does anything you do make the symptoms
r
better? Worse?
Duration—Have you had these symptoms before? If
r
so, when and under what circumstances?
When you are trying to get accurate information,
take care to keep your questions general. If you include
details, patients may use your words instead of their
own in their responses. Follow these tips for getting the
information you need:
Do not suggest answers by the way you ask ques-
r
tions. If you say, “Is the pain worse when you walk?”
patients may say yes because they think that is what
they’re supposed to say.
Do not coax patients by suggesting other symptoms.
r
You may have an idea of what symptoms a patient
is experiencing based on the chief complaint. But it
is better to hear what the patient has to say than to
make suggestions. Some patients will agree to the
symptoms you describe, because they think they
“should” be experiencing them.
Use closed-ended questions to get specic information
r
but avoid feeding the patient too much detail such as
asking “Is the pain sharp?” Some patients might agree
to everything you say. Ask these questions only after the
patient has answered open-ended questions. For example, you might say, “How long have you had this pain?”
Cultural Connection
With the increase of new immigrants to the United
States, it is important for the rst time appointment
with the physician to request that the patient bring
all medications, herbal and supplemental products,
and any other preparations they may have been pre-
scribed or used when in their country of origin. The
Federal Food and Drug Administration (FDA) may not
recognize or have approved all preparations that other
countries allow for use. In some countries, pharma-
cists still customize preparations for patients based
on a written formula provided by the physician. Also,
the FDA generally does not allow travelers to import
medications that cannot be legally prescribed in the
United States, and prescription drugs purchased out-
side the United States might not be allowed even if the
medication could be prescribed in the United States.
For example, travelers must have a prescription from
a US doctor to bring back prescription medicine from
another country, even if the drug is authorized in the
United States and the traveler has a prescription from
a physician in the foreign country. Thus, travelers
wishing to purchase less expensive medicine while
traveling in another country may require a prescrip-
tion from a US doctor and, if required by the foreign
country, a foreign doctor as well.
Chapter 16 Medical History and Patient Assessment 309
C
O
G
In addition to collecting information about the patient’s
medical history, you may need to take physical measurements. Medical assistants obtain
measurements or physical measurements of the patient’s
body. Typically, medical assistants measure the patient’s
height and weight. All measurements are recorded in the
patient’s medical record.
as baseline data. Baseline data are used as a reference
point to compare measurements at later visits. Usually,
an adult’s height is only recorded on the rst visit and
then once a year. The weight and vital signs are taken
and recorded at each visit.
ANTHROPOMETRIC
MEASUREMENTS
anthropometric
Measurements taken at the rst visit are recorded
Weight (Wt)
The patient’s weight is measured and recorded at each
grams, depending on the practices in your medical ofce.
It is especially important to monitor the weight for the
following patients:
Infants
r
Children
r
Elderly patients
r
Pregnant patients
r
Other patients may need special monitoring if they
are trying to lose or gain weight or if they are on medications that are calculated according to body weight.
Certain diseases also require special monitoring. Most
medical ofces have only one scale. It should be placed in
a private location to keep patients from feeling uncomfortable when being weighed. Several types of scales, as
shown in Figure 16-3, are used to measure weight:
Balance beam scales
r
Digital scales
r
Dial scales
r
Balance Beam Scale
Here are the steps to follow when weighing a patient
using a balance beam scale:
1. Wash your hands.
2. Make sure the scale is properly balanced at zero.
3. Ask the patient to remove their shoes and any heavy
outerwear or purses that could distort the reading.
Have a place for the patient to sit while removing shoes.
4. Place a paper towel on the scale before the patient
steps on. Because the patient will be standing in bare
feet or stockings, the paper towel will prevent the
spread of microorganisms.
5. Make sure the patient is facing forward on the
scale without touching or holding onto anything if
possible.
6. Slide the counterweights on the bottom and top bars
from zero to the approximate weight of the patient.
Always begin with the heavier weight bar (bottom).
Each counterweight should rest securely in a notch
with an indicator mark.
7. Adjust the counterweights by small amounts until the
balance bar hangs freely at the exact midpoint.
Figure 16-3 The three types of scales
used in medical ofces include the digital,
dial, and balance beam scale. (Reprinted
from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical
Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
310 Section IV Clinical Medical Assistant Skills
8. To calculate the patient’s weight, add the top reading to the bottom one. For example, if the heavier
bottom counterweight reads 100 and the lighter
upper one reads 16 plus 3 small lines, the patient’s
weight is 116.75 pounds.
9. Help the patient off the scale if necessary. You
should stay close to the patient while he is on the
scale. Anyone can lose his balance when getting on
and off the scale, regardless of age.
10. Discard the paper towel. It also might be necessary
to wipe the platform of the scale with a cleaning
disinfectant.
11. Record the weight in the patient’s medical record.
Be sure to include the date, time, your signature,
and your credentials. If you are measuring the
patient’s height at the same time, you can record
them together.
Digital and Dial Scales
The same steps for using the balance scale are used with
a digital or dial scale; however, there are some differences. A digital or dial scales do not have any counterweights to slide. When you weigh a patient on a digital
scale, read and record the weight displayed on the digital screen. If you weigh a patient on a dial scale, an
indicator arrow will rest at the patient’s weight. Be sure
to read the number from directly above the arrow. If
you take the reading from an angle, you will not see the
correct measurement.
Height (Ht)
Most balance beam scales have a moveable ruler at
the back for measuring height. In some ofces, a graph
ruler is mounted on the wall. More accurate measures
are obtained when a parallel bar is moved down to rest
against the top of a patient’s head. Height is measured
in inches or centimeters, depending on the physician’s
preference.
Follow these steps to measure a patient’s height using
a scale with a ruler or on a wall mount device:
1. If this procedure is not performed at the same time as
the weight measurement, wash your hands rst. Have
the patient sit down and remove his shoes. Place a
paper towel on the scale before the patient steps on.
2. Be sure the patient is standing straight with heels
together and eyes straight ahead. The patient’s posture must be erect for an accurate measurement. The
best measurement of height is made with the patient’s
back to the ruler on the scale, but it is also acceptable
for the patient to face the ruler.
3. Hold the measuring bar perpendicular (at a right
angle) to the ruler.
4. Lower the measuring bar until it rmly touches the
patient’s head. Press lightly if the patient’s hair is full
or high. You do not want to include full hair in the
height measurement.
5. Read the measurement at the point where the bar
slides out of the scale. If measurements are in inches,
convert them to feet and inches. For example, if
the bar reads 65, the patient is 5 foot and 5 inches
(60 inches equals 5 feet). If the measuring bar falls
between two full inches, the height is measured to the
nearest ¼, ½, or ¾ of an inch based on the smaller
lines between the inch markers.
6. When you are nished measuring the patient’s height,
assist the patient off the scale if necessary. Watch for
signs that the patient is unsteady.
7. Have a place for the patient to sit to put on his shoes.
8. Record the patient’s height in the medical record.
9. Discard the paper towel and wipe the platform of the
scale with a cleaning disinfectant.
Physical Measurements of Children
An infant’s length (height) and weight are measured at
every routine visit. You may also need to measure an
infant’s chest and head circumference. These measurements help the physician monitor the infant’s growth
and development.
Procedures for measuring an infant’s weight and
length are somewhat different from those for older children and adults. Pediatric (infants and children) weights
and heights are often recorded on a growth chart as
well as in the patient’s medical record. The growth chart
provides a graph of the child’s growth patterns and the
percentile the child falls within. Charts are available
based on the child’s age and gender. Figure 16-4 shows
a growth chart that would be used to record measurements for a female child from birth to 36 months.
Measuring Infant Length
To measure infant length, you need an examining table
with clean table paper and a tape measure. Always wash
your hands rst. Explain the procedure to the parent. Ask
the parent to remove the infant’s clothing, except for the
diaper. Follow these steps for measuring infant length:
1. Wash your hands.
2. Place the infant on a rm examination table covered
with clean table paper. You need a rm surface for
accurate measurements. If you are using a measuring
board, it should be covered with clean paper.
3. Hold the infant’s head at the midline. Fully extend
the infant’s body by grasping the knees and pressing them at onto the table. Most infants stay in a
exed position, so you need to extend the legs to get
an accurate measurement. Be gentle, but rm. If you
need help, ask the parent or a coworker to help you.
A footboard against the soles of the infant’s feet will
give the most accurate measurement.