Identifying the Patient, Taking the History, Documenting

This is Unit Eleven of Medical Assistant Prep. Units Seven through Ten kept patients and staff safe. This unit begins the clinical visit itself: confirming who the patient is, taking the history, and writing it into the record. Carry one idea through this lecture. The medical assistant gathers the subjective and objective data that start the provider's note, in the patient's own words and as measured, and interprets none of it. Two constructed cases at the end show that idea, one with an interpreter. By the end you will be able to confirm identity and allergies. To set the conditions for an accurate interview. To take the parts of a health history and explore a symptom. And to document as a legal record.

Four entries on the basics: identifiers, allergies, subjective and objective data, and sources.

Before any care.

MAS 251 Identify the Patient First

Before any care, confirm the patient's identity with at least two identifiers, following the practice's policy. Common identifiers are the patient's full name and date of birth, checked against the record or the order in front of you. Check the identifiers against the record every time, even for a patient you know well.

Every visit.

MAS 252 Ask About Allergies Every Time

Confirm allergies at every visit, along with the patient's identity. Ask what each allergy is, including medications, foods and latex, and how the patient reacts to each; a rash and trouble breathing are very different reactions. A new allergy since the last visit is easy to miss unless you ask every time.

Reported and measured.

MAS 253 Subjective and Objective Data

Information gathered about a patient is either subjective or objective. Subjective data is what the patient reports, such as "I have a headache"; objective data is what you observe or measure, such as a temperature or a visible rash. Record subjective data in the patient's own words, and objective data as measured.

Patient first.

MAS 254 Primary and Secondary Sources

The patient is the primary source of information about their own health. Secondary sources include the chart, family members and other members of the care team; they help, especially when a patient cannot answer. When a family member answers for a capable adult patient, gently ask the patient too.

Three entries on the conditions for accurate answers: rapport, a medical interpreter, and cultural safety.

Before sensitive topics.

MAS 255 Build Rapport Before Sensitive Questions

Establish rapport with a patient before asking about sensitive topics, so that the answers are accurate. Introduce yourself, explain why you are asking, choose a private setting, and give the patient time to answer without feeling rushed. If a barrier to communication exists, adapt your approach to the patient's needs.

Not family.

MAS 256 Use a Medical Interpreter

If a patient's primary language is not English, arrange for a medical interpreter before taking the history. Family members or care partners should not interpret for the patient, even when they offer. A relative may soften, skip or change what is said, and the patient may hold back in front of them.

Open, not assuming.

MAS 257 Cultural Safety

Cultural safety means creating a space where patients can speak with health professionals without judgment or discrimination. Ask open questions about beliefs and practices that matter to the patient's care, rather than assuming based on appearance or background. Avoid questions that assume, such as "Are you married?"; ask about relationship status in open terms instead.

Nine entries on the history: its parts, demographics, the reason for the visit, symptom questions, medications, family and function.

What a full history covers.

MAS 258 The Parts of a Health History

A comprehensive history covers six areas, mostly subjective data: demographic and biological data such as name, date of birth and allergies; the reason for seeking care; current and past medical history, including medications; family health history; functional health, meaning daily activities, sleep, nutrition and relationships; and a review of body systems. The practice decides which parts the medical assistant collects at each visit. A routine follow-up may need only an update, so do not repeat a full history unless asked, and never skip allergies and medications.

Names, pronouns, contacts.

MAS 259 Demographic Questions

Demographic data includes name, contact and emergency contact, date of birth, gender, preferred language and resuscitation preferences. Ask what the patient prefers to be called and which pronouns they use, and whom to contact in an emergency and at what number. Ask, rather than assume, about names, pronouns and relationships.

Open first, then focused.

MAS 260 The Reason for the Visit

The reason the patient is seeking care, often called the chief complaint, guides the rest of the interview. Use open-ended questions such as "What brings you in today?" so the patient can explain in their own words, then ask focused questions to fill in details. If the answers do not seem to fit together, keep asking gently until they do.

Exploring a symptom.

MAS 261 Exploring a Symptom With P, Q, R, S, T and U

A symptom can be explored with six questions, P through U. P is provocation and palliation: what makes it worse or better. Q is quality: aching, stabbing or burning. R is region: where it is and whether it spreads, and the patient can point. S is severity, from zero to ten. T is timing and treatment: when it started, whether it comes and goes, and what the patient has taken. U is understanding: what the patient thinks causes it. Record the answers in the patient's words and leave interpretation to the provider. These questions gather information, not a diagnosis.

The patient's number.

MAS 262 Rating Severity From Zero to Ten

A common way to rate pain or another symptom is a scale from zero to ten. Zero means no pain, and ten means the worst pain the patient has ever experienced; the same scale can rate shortness of breath or other symptoms. The number is the patient's rating. Record it as given, even if the patient looks comfortable.

Prescribed and not.

MAS 263 The Medication History

A medication history includes prescriptions, over-the-counter medicines, vitamins and herbal supplements. Ask what each one is for, and whether the patient takes it as prescribed; if the answer is "sometimes," ask openly about the reasons. Patients often leave out supplements and over-the-counter medicines unless you ask by name.

Risk, not destiny.

MAS 264 Family Health History

Many diseases have a genetic component, so the history includes the patient's close blood relatives. Ask about the health, age and, where it applies, the cause of death of parents, brothers and sisters, and children. Family history shows risk, not destiny. It is a reason for screening, not a diagnosis.

Daily life and support.

MAS 265 Daily Functioning

Functional health describes how the patient manages daily life: activities, nutrition, sleep, roles and relationships. Questions cover how the patient eats and sleeps, whether they need help with everyday activities, and whom they rely on for support. Signs of isolation or a lost support system are worth noting and passing on to the provider.

When the interview stops.

MAS 266 Findings That Cannot Wait

Some answers during the history call for immediate notification of the provider or emergency care, according to the practice's policy. A report of chest pain or difficulty breathing ends the routine interview, and the provider is called at once. Finish the paperwork later. The patient comes first.

Six entries on documentation and questioning: the legal record, the progress note, prompt recording, question types, and two constructed visits.

Accurate, prompt, unaltered.

MAS 267 The Record Is a Legal Document

Everything written in the health record is part of a legal document. It must be accurate and completed promptly, and it should never be altered, deleted or falsified; abbreviations should be avoided in legal documentation. Write only what you saw, heard, measured or did, and sign it as yourself.

S, O, A, P, I and E.

MAS 268 The Progress Note and Your Part in It

One common progress-note format follows the letters S, O, A and P, sometimes with I and E. S is subjective, what the patient said. O is objective, observable and measurable data such as vital signs and results. A is assessment, the interpretation of S and O, which in a provider's note is the diagnosis. P is the planned care. I is interventions, the actions taken, and E is evaluation, how the patient responded. The medical assistant mainly gathers the S and O that form the note's foundation. Assessment and plan need clinical judgment and belong to the provider, so never write a diagnosis into S or O.

Not at day's end.

MAS 269 Document Promptly

Record care as soon as it is given, not at the end of the day. Delayed documentation leads to errors, such as a second dose given because the first was not yet recorded, or a reading forgotten before it was written down. If you are interrupted, finish recording before you start the next task.

Explain, then pin down.

MAS 270 Open and Focused Questions

A good history combines open-ended questions with focused ones. Open questions such as "Tell me more about that" let the patient explain; focused questions such as "Did the pain start before or after eating?" pin down specific details. Use focused questions to fill in details the patient has raised, not to steer them toward an answer.

One patient, roomed.

MAS 271 Rooming a Patient

A constructed rooming pays off the opening idea. The assistant introduces herself, confirms name and date of birth, and learns of a new allergy, a rash after an antibiotic last month, which she records with the reaction. He says his knee has been killing him since a fall on the stairs, and she records his words. The six questions follow: walking worsens it and ice helps a little; it aches on the inside of the right knee; he rates it six; it began four days ago and is constant; he has taken an over-the-counter reliever; he thinks he twisted it. Asking by name surfaces a vitamin too. She records vital signs and tells the provider about the new allergy. She suggested no sprain and wrote no assessment.

A history through an interpreter.

MAS 272 An Interview With an Interpreter

A second constructed case shows a history across a language. An older woman's adult son offers to translate. The assistant thanks him and arranges a medical interpreter by phone, as policy directs. She asks one question at a time and waits for full answers, and records a home remedy by the name the patient gives. Before a sensitive question she asks whether the patient wants her son to step out, and she does. Then the patient mentions dizziness she had kept from him. The assistant records it in her words, tells the provider, and notes the interpreter's identification as required. The son's offer would have been faster and would have cost the visit's most important answer, which is why a trained interpreter is the standard.

Look at what you can now do. You can confirm two identifiers and allergies at every visit, and tell subjective data from objective. You can build rapport, arrange a medical interpreter instead of a relative, and ask open questions that assume nothing. You can take the parts of a health history, explore a symptom with six questions, and stop the interview for chest pain or trouble breathing. And you can document promptly in a legal record, gathering the subjective and objective data while leaving assessment to the provider. Unit Twelve turns to the first measurements: temperature, pulse and respiration.