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Tips for Taking a Patient Medical History

Nurse holding clipboard and speaking with patient

Medical assistants help medical professionals with regular clinical duties. However, they are also responsible for a variety of administrative duties, like updating, organizing, and filing patient medical records. One of those duties requires that you gather a patient’s medical history. Accurate and correct patient medical records are essential for keeping medical operations running smoothly and making it easy for patients to receive healthcare. There are many things that medical assistants can do to ensure they are receiving detailed information from patients.

Prism Career Institute provides a Medical Assistant program in Philadelphia, PA, and in Cherry Hill and West Atlantic City, NJ, designed to give students the resources they need to succeed as medical assistants. Here, we discuss tips medical assistants can use to successfully collect a patient’s medical history and other information.

Create a Checklist

Because there are so many questions to keep track of when inquiring about a patient’s medical history, medical assistants should craft a checklist. This way, you can make sure you are gathering all the information necessary. Depending on the medical field you work in, you may need to ask more targeted questions about a patient’s lifestyle. For example, those who work in women’s health care may need to ask questions about a patient’s reproductive health, like sexual history, symptoms of reproductive systems, and contraception.

However, most medical assistants across all fields generally bring up the following:

  • Greet patients and introduce yourself
  • Ask why the patient is being seen
  • Inquire about previous medical and surgical history
  • Ask about allergies and current medications
  • Request information about family medical history
  • Ask about social history, as well as smoking and drinking

At the end of the session, medical assistants should see if the patient has any questions and take time to respond. Students can begin creating their mental checklist by gathering experience through medical assistant externships and other opportunities.

Establish Trust With Patients

Medical check-ups and other procedures can be anxiety-inducing for some patients. That’s why it’s important to create trust before gathering medical information. The process of collecting a patient’s information is a personal one, as patients are sharing some of the most intimate details about their lives. This means building trust allows them to feel comfortable with opening up. In turn, they can receive treatment and you can promote a positive patient experience.

One way that medical assistants can build trust is by making the process more of a conversation. Shooting many questions at patients in a short time can make the appointment feel cold and procedural. However, taking the time to slow things down and asking more personable questions can allow the appointment to feel more relaxed and comfortable. Try relating to fun activities your patient does in their free time or finding another common ground.

In addition, the tone of your voice should remain neutral while asking about a patient’s medical history. This is especially true when discussing sensitive topics, like sexual history, alcohol usage, and smoking habits. If healthcare professionals show judgment or disapproval, this can cause patients to shut down and hold back essential information. Medical assistants should also remember to use common terminology when referring to medical procedures and practices. Using medical terms can confuse patients, making them uneasy and unsure about what is going on.

Ensuring patients are comfortable throughout their appointment is one of many responsibilities of medical assistants, as stress and anxiety can actually alter the results of tests, for example, a blood pressure check. Not only can building trust with patients ensure you have accurate patient records, but it also allows appointments to run smoothly.

Double Check Medical History for Accuracy

Making sure that patient medical records are correct and updated is an essential role of medical assisting. This is because they are used for ensuring accurate patient diagnoses and insurance and billing purposes. After inquiring about a patient’s medical history, your records should be detailed and complete. To ensure you have gathered all information, you should make sure to effectively listen to patients, being sure not to interrupt them while they’re talking.

It can also help to offer specific examples when talking about medical history and medications. This way, it triggers necessary information for more accurate records. If a patient is visiting because of uncomfortable symptoms, medical assistants should be sure to ask questions centered on the patient’s issue. This allows you to collect the information needed to come up with an accurate diagnosis. Another helpful tip is that you should repeat the patient’s answers back to them. This gives patients the chance to change or correct their answers.

Lastly, medical assistants should make sure to ask about the patient’s personal life. Some symptoms can arise due to stressful life events or other circumstances. Inquiring about a patient’s personal life can help accurately determine the cause of a patient’s condition and the best way to go about treatment.

Start Your Career Journey Today

Prism Career Institute teaches students how to thrive in the medical industry, highlighting essential skills, like gathering medical history, through combined classroom instruction and hands-on learning. We have campuses in Philadelphia, PA, and Cherry Hill and West Atlantic City, NJ. To learn more about our Medical Assistant program, contact us or apply online today.