As a medical assistant, it is your job to prepare the patient and the patient's chart before the physician enters the exam room to examine the patient. You are the first contact with the patient in the exam room. How you conduct yourself during those first few moments can make a major difference in the patient's attitude and perception of the medical office. The patient must cooperate fully to provide the information the physician needs to diagnose and treat the patient successfully. Conducting the patient interview and recording the necessary medical history are essential to the practitioner's exam process.

Outline

• The Patient Interview and History
• Your Role as an Observer
• Documenting Patient Information
• Recording the Patient's Medical History

Learning Outcomes

After completing Chapter 36, you will be able to:

 36.1 Name the skills necessary to conduct a patient interview.
 36.2 Explain the procedure for conducting a patient interview.
 36.3 Recognize the signs of anxiety; depression; and physical, mental, or substance abuse.
 36.4 State the six Cs for writing an accurate patient history.
 36.5 Document on the patient's chart accurately.
 36.6 Obtain a patient history
 36.7 Identify parts of the health history form.

Summary

As a medical assistant, you will play a key role in a patient's visit to the physician's office. Because you will begin the exam by interviewing the patient, you will set the tone of the visit. Keep in mind that some patients may be nervous or uncomfortable. It is important to make them feel at ease. Using interviewing skills effectively will help make the interview productive as well as comfortable for the patient. Taking a thorough history and using proper documentation methods will also allow you to ensure that patient records are complete and accurate. They will also help the practitioner to diagnose and treat the patient successfully.