Preparing the Patient for Examination

Preparing the Patient for Examination Patient interview - Answer- The first step in the examination process. It establishes a relationship between the medical assistant and the patient, and it allows the medical assistant to collect information and data pertinent to the patient's well-being. The health history form - Answer- The medical office usually has a standard medical history form that it uses for all patients. The specific arrangement and wording of items vary from office to office. Personal data - Answer- This information is obtained from the administrative sheet and includes things like the patient's name, Social Security number, birth date, and other basic data. Chief complaint - Answer- Abbreviated as CC, it is the reason the patient came to visit the practitioner. It should be short and specific and cover subjective and objective data. History of present illness - Answer- This includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem (including any medications taken). For example, a chief complaint might be "sore throat," and the history of the present illness would include when the sore throat started, how severe the pain is on a scale of 1 to 10, and what treatments have been used. Past medical history - Answer- The past medical history includes any and all health problems both present and past, including major illnesses and surgery. The past medical history also includes important information about medications and allergies. Family history - Answer- This section includes information about the health of the patient's family members. Many times the family history can help lead a practitioner to the cause of a current medical problem. Obtain specific information about family members' current ages and medical conditions or, if deceased, their age at death and the cause. Social and occupational history - Answer- Information such as marital status, sexual behaviors and orientation, occupations, hobbies, and use of chemical substances help determine a patient's risk for disease. Patients should be asked about their use of alcohol, tobacco, recreational drugs, or other chemical substances. Six Cs of charting - Answer- •Client's words—The patient's own phrasing must be recorded exactly.•Clarity—Use precise medical terminology. •Completeness—The chart must contain all pertinent information.•Conciseness—Use abbreviations where you can to save time and space.•Chronological order—Date all entries.•Confidentiality—Protect the patient's privacy. Interviewing successfully - Answer- Do your research before the interview. Review the patient's medical history. Plan the interview. Plan what types of questions you want to ask. Approach the patient and request an interview. Make the patient feel part of the process. Make the patient feel at ease. Use icebreakers and casual conversation.Listen to the patient.Conduct the interview in private without interruption. Do not diagnose or give a diagnostic opinion. Summarize key points, and let the patient ask questions. Methods that can further help you collect patient data include - Answer- Asking open-ended and hypothetical questions, mirroring the patient's explicit responses and verbalizing the implied responses, focusing on the patient, encouraging the patient to take the lead, encouraging the patient to provide additional information, and encouraging the patient to evaluate the situation. Make sure that you do not challenge the patient or probe in a manner that invades the patient's privacy. Detect nonverbal clues - Answer- During the preexamination interview, you may note things that patients have not communicated to you verbally, such as anxiety, depression, signs of physical or psychological abuse, and signs of drug or alcohol abuse. If you suspect abuse, bring it to the physician's attention immediately. Provide such patients with support, advice, and the appropriate hotline number for your area if they want to seek help. Purpose of the physical examination - Answer- The determination of the general state of health of the patient and the diagnosis of any medical problems and diseases the patient may have. The physician uses a variety of devices and laboratory tests to complete the physical findings. The majority of physicians usually start at the patient's head and end at the feet. Sometimes the physician may order some additional tests or procedures, such as blood sample testing, the collection of culture specimens, or X-rays. Complete physical examination - Answer- Includes vital signs, examination of the patient's entire body, laboratory tests (complete blood count [CBC] and urinalysis); and diagnostic tests (X-rays). Duty of a medical assistant - Answer- Preparing the room and equipment, getting the patient ready, and assisting the physician. Emotional preparation - Answer- Begin by explaining what will happen during the examination. This step is especially important when dealing with children. Physical preparation - Answer- The medical assistant is responsible for obtaining and recording weight, height, and vital signs; facilitating the examination; asking the patient to empty his or her bladder; asking the patient to disrobe completely; providing the patient with a full gown; and providing a drape sheet. Examination methods - Answer- The six methods for examining a patient that are a part of a complete physical examination are inspection, palpation, percussion, auscultation, manipulation, and mensuration.