Why does the medical assistant ask you so many questions at the beginning of a physician’s appointment? As a medical assistant, they are preparing the physician with important information. The medical assistant focuses on information gathering to allow the physician to spend more time on patient care. Are you interested in becoming a medical assistant? During the Medical Assistant program at Meridian, you will learn how to take a patient’s health history to be ready when you start your new career.
What is a Patient’s Health History?
At the beginning of a patient’s admission, the medical assistant reviews the patient’s history to get abreast of any changes the physician should know about. The health history records a patient’s symptoms, including allergies, illnesses, surgeries, immunizations, test results, and other important medical information. The medical assistant reviews the following topics with the patient:
Chief Reason for the Visit
What is the patient experiencing, how severe are the symptoms, what is the pain level, and has it progressively worsened? The medical assistant must understand why the patient is seeing the physician. Is it a routine checkup? Does the patient have pain or discomfort? Are they learning about the results of a test? Knowing why the patient is at the doctor’s, the medical assistant reviews the suitable topics and asks the best questions.
Allergy Review
One of the most critical pieces of information a medical assistant can review with the patient is their allergies. Is the patient allergic to latex? If so, the medical assistant and physician must wear alternative PPE to examine the patient. Are they allergic to penicillin? The physician may need to prescribe an alternative antibiotic.
Surgical History
Understanding and updating recent surgical procedures can shed light on symptoms a patient is experiencing. Did the patient have a hip replacement, and are they experiencing pain due to the surgery? Does the patient need physical therapy to reduce pain and improve their range of motion? Physicians can learn much about a patient when they have the correct information.
Current Medications
The medical assistant will verify the list of medications that the patient is currently taking. Since most patients see multiple doctors, it is essential to update the electronic health records so all doctors administering care to a patient are informed of the medications they are taking. Medications have side effects, which may be the chief reason for the visit or cause the physician to choose different medications due to contraindicators. Either way, the medical team must understand the drugs a patient takes.
Vaccinations
Before the physician examines the patient, the medical assistant will inquire about influenza and COVID-19 vaccines. If the physician thinks that the patient needs an additional vaccine, they may order the medical assistant to administer the vaccine at the end of the exam.
Test Results
Reviewing test results with the patient at every exam is critical to ensure accurate information in the electronic health records. For example, a patient may go to urgent care if they are experiencing symptoms, and the physician may order tests to understand better why the patient is experiencing discomfort. Suppose the urgent care facility is not connected to the health services network insured by the patient. In that case, the medical assistant must inquire about test results that aren’t on the electronic health records. That way, the physician has all the information they need to make accurate diagnoses and treatment decisions. Plus, they will not duplicate tests and waste resources.
Health History
Patients may be reluctant to offer information about their health history or need a reminder of health problems they have experienced since the last visit. The medical assistant must ask open-ended questions to let the patient elaborate on their answers. Asking a yes or no question facilitates a patient to withhold health history information.
For example, a patient may say that they are experiencing hearing loss. The medical assistant can alert the physician to do an ear examination during the appointment. Maybe the patient has too much wax in their ear and needs to remove it. In this situation, the physician will order an ear irrigation, which the medical assistant will perform. The medical assistant will use a high-pressure flow of water to dislodge the wax from inside the ear canal and then use a scoping tool to remove any large particles that may be causing the hearing loss.
The medical assistant may also inquire about a patient’s exercise routines. Whether they smoke, drink alcohol, get regular exercise, or drink caffeine. Understanding a patient’s exercise levels can tell the physician much about the patient and what treatments may be helpful. For example, a patient with Type 2 diabetes may be encouraged to adhere to an exercise regimen to lower blood sugar levels to supplement medication intervention.
Who is Responsible for Recording the Patient’s History?
The medical assistants are responsible for recording the patient’s history for the physician to review. However, the medical office assistant can help by entering the information into the electronic health records so that all the medical professionals the patient sees know their health history.
What is the Importance of a Patient’s Health History?
Physicians recommend that medical assistants ask patients for their health history each time the patient has an appointment. This way, the physician can identify trends and find patterns to shed light on symptoms. For example, a patient may have a higher-than-normal temperature on the exam day. However, the physician may look back at previous readings to see whether this is normal or a symptom of something else that the physician should investigate. The more information a physician has, the better decisions they can make, leading to better health outcomes.
Want to Learn More?
Meridian College offers a hands–on Medical Assistant training program taught by experienced school faculty who know how to prepare you for the daily challenges you’ll face on the job. From assisting doctors with patients to critical administrative tasks, our experienced teachers will train you for a rewarding new career.
Contact Meridian College today to learn more about becoming a medical assistant.