copyright ©2012 delmar, cengage learning. all rights reserved. chapter 37 the medical history and...
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Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Chapter 37
The Medical History and Patient Screening
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Patient Screening
• The process of obtaining information and determining the best action to take (and in what priority)
• Types: Phone, In-person• Originated from the concept of triage
– Used by the military– Prioritizing the conditions of the injured following
a disaster
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
In-Person Screening
• Performed in a private area or exam room• Requirements
– Professional communication skills – Privacy and confidentiality– Follow the Patient Bill of Rights
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
In-Person Screening
• Goals– Find out why the patient is seeking health care– Determine the patient’s main problem (CC)– Note any other patient concerns– Discover what remedies or treatments the patient
has already tried
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Factors Influencing Screening
• Be aware of your biases and nonverbal cues– Be open when approaching patients– Treat all patients with respect, regardless of age,
religion, race, or financial status• Establish a non-threatening environment• Ensure patient understanding
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Conducting In-Person Screening
• Use open-ended questions– Patient will have completed a health history form– Let the patient do most of the talking– Ask what brought the patient to the office
• Develop the chief complaint• Document in the chart or EMR• Conclude with a summary
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
The Health History
• Includes all information about the patient and the patient’s family– Acquired from all new patients
• Purpose of the health history– Basis for understanding present health status– Basis for guiding treatment from the provider– Can provide statistical data
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Reviewing the History Form
• Provide a private area• Introduce yourself and build rapport• Review information with patient for clarity and
completeness– Ensure clear communication– Use effective techniques
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Sections of the Form
• Chief complaint– The reason the patient is seeking care at that visit– Use the patient’s language– Should include subjective symptoms and objective
findings• Subjective: Symptoms or feelings that only the patient
can perceive• Objective: Symptoms or information that can be
observed
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Sections of the Form
• Present illness and history of present illness• Medical history and past medical history
– All problems, surgeries, illnesses, disorders that have ever been diagnosed
• Include usual childhood diseases
– Current medications– Any known allergies
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Sections of the Form
• Family health history– Age and health status– Immediate family, grandparents, aunts and uncles
• Social and occupational history– Patient’s personal or lifestyle habits– May be sensitive in nature– Work history, drug usage, living environment,
hobbies, diet and exercise
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
After the History is Complete
• Take patient’s mensurations and vital signs• Prepare the patient to be seen by provider• Provider performs a Review of Systems
– Systematic check of each body system– Provides a baseline for future visits– Documented on the health history form
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