What is Important about Taking Health Histories?

Medical assistants do more than answer the phone and take vital signs. They prepare patients for their visit by taking health histories and screening for troublesome symptoms. Done thoughtfully, these pre-exams are as important as the physical examination that follows. Accurate information is the key to quality care.

Rooming Patients: A Medical Assistant’s Step-by-Step Guide to Pre-Exams

Medical assistants escort patients to exam rooms after check-in. Called “rooming,” it involves making them comfortable while completing clinical tasks that provide critical health data. The process includes:

Making Clinical Observations

Your clinical observations should begin the moment a patient arrives. How are they moving? Do they appear anxious? Are they coughing or short of breath? Because people aren’t always able to describe their symptoms clearly, reporting what you see and hear gives doctors an advantage.

Reviewing Records

It’s important to review a patient’s health details and the reason for their visit before performing clinical tasks. If they’re complaining of an irregular heartbeat, for example, the process for obtaining a pulse is slightly different.

You’ll also check for red flags, contraindications for certain procedures, such as allergies. EMR software also highlights overdue services, such as an influenza vaccine, or tests the doctor wants results for before seeing the patient. Mentioning these upfront helps keep the client informed and avoids surprises.

Collecting Specimens

If the provider wants blood or urine tests done before the exam, you’ll work with the client to collect a sample. A quick urinalysis can point to diabetes rather than infection among patients complaining of excessive urination, so having results in advance saves the doctor and patient time.

Updating Medication and Allergy Lists

Medication and allergy lists are updated at each visit, allowing patients to confirm which drugs they take and how often. You’ll ask which over-the-counter medications they use, some can interact with prescription drugs, and if they’ve experienced any unwanted side effects. The doctor will then discuss concerns with the patient based on your notes.

Depression Screening

Millions of adults suffer from depression. However, the symptoms are difficult to recognize, so patients don’t always report them.

As a medical assistant, you will perform a screening test called the PHQ-9. A series of questions designed to detect depression symptoms. A positive result is the first step for many toward getting treatment. Depending on where you’re employed, you may also screen patients for other issues from home safety to financial needs. Practices use this information to recommend community support services.

Physical Preparation

Some exams require that patients change into a hospital gown. You’ll offer the appropriate garments while providing privacy and mobility assistance if needed.

Vital Signs

Vital signs, fundamental indicators of health, are obtained at each visit. Which you take depends on where you work and the patient’s complaints.

What Are Some of the Vital Signs Taken During a Pre-exam?

Today’s medical assistants regularly take these five vital signs:

Temperature

Taken with an oral, temporal, or tympanic thermometer, changes in body temperature may reflect illness. The normal adult temperature averages 98.6 °F, but a fever is defined as two degrees above baseline. Checking the records for past readings is a must.

Pulse

Pulse, or heart rate, is measured by counting the vibrations in arteries near the skin’s surface. At the wrist above the radial artery is the most common site.

You’ll count the pulses for 15 seconds and multiply the result by four to get a one-minute reading. If, however, the patient’s health history shows a dysrhythmia, you’ll count for a full minute, noting the rhythm, character, and strength of the pulse.

Respiratory Rate

To measure respiratory rate, medical assistants count the patient’s inhalations for 30 seconds, multiplying the result by two for a 60-second reading. Do it without making the patient aware so that anxiety won’t affect their breathing pattern.

Blood Pressure

Blood pressure is called the silent killer because it rarely causes symptoms. Yet the excessive pressure of blood against artery walls can result in heart disease and organ failure if left untreated.

Taken with a digital meter or a manual sphygmomanometer and a stethoscope, blood pressure is measured at each visit so that the doctor can monitor trends. You’ll learn both methods in a vocational medical assisting program.

Oxygen Saturation

Oxygen saturation testing shows how much hemoglobin blood contains. Hemoglobin carries oxygen, so it’s a critical parameter for diagnosing heart and lung disorders. Easy to measure, you’ll clip an electronic meter to the patient’s finger, and the machine does the rest.

What’s So Important about Taking Health Histories?

The patient’s health history is the foundation upon which all care is based. The information should be complete, timely and relevant. Accuracy matters because:

The Data Is Used to Make Medical Decisions

Parts of a patient’s medical record are used to make most treatment decisions. Before prescribing an antibiotic, for example, doctors check the allergy list. And some people can’t tolerate strong prescription drugs because of their effect on the kidneys or liver. Prescribers review lab data before choosing medications, so all recent reports must be present.

It Follows the Patient Wherever They Go

Accurate medical records ensure good continuity of care, treatment received over time from multiple providers. The recent opioid epidemic demonstrates why specialists need to know what primary care physicians have already prescribed. Multiple prescriptions for the same drug may result in unintentional overdoses.

Patients can also expect safer emergency care based on the data in their health history. When someone is brought to the ER unconscious without an obvious cause, it’s helpful for providers to know what medications they take, which vaccines they’ve had, and if they’ve been treated recently for a serious illness.

It Affects Billing

Medical billing is often predicated on symptoms. Insurers decide whether services are warranted based on best practice guidelines and the health information in the chart. When a doctor prescribes an antidepressant for a mood disorder, their notes must clearly explain why the treatment was chosen. No policy pays for antidepressants for gastrointestinal symptoms.

What Are Some of the Diseases and Disorders that Can Be Identified with Vital Signs and Health Histories?

Vital signs and health histories help doctors spot these common disorders:

Allergies

Medication allergies can cause itchiness, hives, or vomiting. Most sensitivities are self-reported, but doctors may suspect unidentified allergies based on symptoms.

Heart Disease

Heart disease has a significant genetic component. That’s why initial health histories ask about illnesses that run in the family. Familial hypercholesterolemia, high cholesterol based on genetics not diet, increases a patient’s risk of heart disease. People with a family history of this and similar conditions are screened earlier and tested more often than others for early heart issues.

Diabetes

Like heart disease, diabetes also runs in families. A patient with one diabetic parent has a 25% greater chance of developing the illness. Two parents with it raises the risk to 50%.

Heart Dysrhythmias

Patients without symptoms are rarely screened for abnormal heartbeats. Yet we know that one dysrhythmia, atrial fibrillation, is a leading cause of stroke. The first sign of trouble is often an irregular pulse.

Infections

Health histories and vital signs both help diagnose infections. If records show someone was vaccinated for the flu, for example, symptoms like shortness of breath may point to a different cause. An up-to-date health history helps narrow down potential diagnoses.

Common symptoms of infections also include a fever and high or low blood pressure depending on the type and severity. Oxygen saturation readings drop quickly when the lungs are involved.

Anemia

Anemia is a low red blood cell count. Symptoms include fatigue, shortness of breath and palpitations. Oxygen saturation levels and blood pressure tend to be low while the heart rate can be irregular. Abnormal vital signs support the need for further testing.

Hypertension

Hypertension is one of the few disorders that can only be diagnosed by taking vital signs. Physical symptoms are rare until the damage is done.

By taking a reading at every visit, doctors can observe trends over time, prescribing medication or lifestyle changes before high blood pressure causes organ damage. Medical assistants are lifesavers.

How Do You Learn More about Interacting with Patients as a Medical Assistant?

Taking accurate health histories requires good people skills. You’ll need to build rapport with patients before they’re comfortable enough to speak honestly about sensitive personal issues.

Vocational school medical assisting programs not only train you to take accurate health histories, but they also cover therapeutic communication techniques that let you better connect with people. You’ll practice with peers in the classroom and with patients during clinical externships, experience teaches you the rest.

Final Thoughts

Medical assistants have too many responsibilities to count, but some matter more than others. Taking accurate vital signs and thorough health histories are among the most impactful.

Want to Learn More?

The objective of this Medical Assistant training program at Peloton College is to prepare the student for employment as an entry-level Medical Assistant performing administrative, clerical, and clinical duties within the health care field.

The mission of Peloton College is to be the premier provider of hands-on training and education by providing students and graduates with the necessary skills to secure occupational careers. Contact us today to learn more.