Medical History And The Aspects Of A Successful Interview With A Patient
A patient’s medical history is obtained in detail on the first visit. After that the information is updated at every visit. There are various sections/ components to this history. Firstly we need to obtain the Chief Complaint; which is the reason the patient came in for the visit. It is easily done on an EMR which has drop down boxes and helps us take a very detailed history without missing key information. The CC is subjective, based on what symptoms the patient feels. Next are details about the Present Illness. How & when this problem started, whether they have done anything prior to coming in to alleviate their symptoms. Then the Past Medical History is noted about prior illnesses, surgeries, pregnancies; all diseases and disorders the patient has had in the past. Family health history, social history, ROS, allergies are also asked in detail and the different sections of the EMR are filled in.
To have a successful interview, the patient must be taken to a private area where they are comfortable and can speak freely. Generally done in the examination room before the patient undresses. The MA should be facing the patient, making frequent eye contact & give the patient adequate time to answer the questions in their own words. Try to keep the patient on topic with the use of both open ended questions & also closed ended questions.
Examining a patient without them feeling uncomfortable is an art. I have taken an ECG on a patient who was very breathless & could not lie down on the narrow examination table comfortably. So firstly I put the table into a semi-Fowlers position. Then helped the patient onto the table after she had removed her outdoor clothing including tights. Next I gave her a blanket to cover herself, and while she was adjusting herself to the position she had to lie in, I was talking to her to enter information into the machine. When she was comfortable, I applied the electrodes to her extremities and chest and quickly took the reading after asking her to take a deep breath and hold her breath for a few seconds. Once the procedure was over, I helped her into an upright position and gave her a foot-stool and helped her off the table.
Talking to distract her and being quick and efficient while doing the procedure overcame her physical barriers to the exam.