1. The Medical History and Patient Screening
Chapter 37
The Medical History and Patient Screening

2. 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

3. In-Person Screening Performed in a private area or exam room
Requirements
Professional communication skills
Privacy and confidentiality
Follow the Patient Bill of Rights

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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