Tips to Efficiently Take Patient Histories

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Tips For Medical Assistants That Matter

Taking a patient clinical history is more than going through a checklist of items and coming to an immediate conclusion based on black and white assessments. That’s why it’s important to develop a strong understanding of why history taking is essential to patient care.

Having a personal conversation with the patient can inform you more than just going through a list of yes and no type medical questions.

If you work in healthcare, and this is part of your role, these insights and tips are meant to help you understand how you can be more effective when taking patient histories. By becoming a rock star history taker, you can better prioritize with your NP or MD and help plan the highest quality of care for your patients.

Keep in mind that patient assessment wasn’t even a priority until the 1970’s. This practice of assessment seems like a no-brainer to today’s workforce, but the importance and complexity of history taking cannot be over-stated.

That’s why we are still learning new information about history taking with more focus, conversation, research and analysis of this medical necessity.

Medical assistant with patient

Keys to Getting a Thorough Medical History

Have a conversation. Like we stated earlier, history taking isn’t a checklist you should whip through to get on with your time. This is when you really start creating the roadmap for care. Having a relaxed patient and developing an honest rapport is the best way to acquire the right information. There are situations when you may need to get to know family members who know your patient well, and may be part of the key to delivering the necessary care for your patient. Getting to know your patient will help you better understand their emotional health, which can be overlooked, if not actively observed.

Practice empathic listening. Try to hear your patients and understand their emotional state as best you can. While it can be easy to get distracted it’s hard to tame your mind like a Buddhist monk, so just try to actively listen as you sit down with each patient. History taking outcomes not only involve defining your perspective on the patient’s condition, but can also involve putting the patient’s mind at ease, explaining complicated healthcare information in ways they can more easily digest. Try to be ‘at one’ with your patient, as the Zen philosophers might instruct.

Communicate with your peers and superiors. Clinical history taking skills cannot be perfected by yourself. Your own direct patient experiences may shape you in big ways, but watching other MAs, nurses and doctors communicate with the patients can give you new insight and unexpected knowledge that you can use on your own patients. It also never hurts to simply ask your peers or others in your facility is they have any advice or ideas for history taking. This can be helpful if you are working on a team. Any conversation that centers around finding a better understanding of your patient will only heighten the quality of care your team provide

Ask open and closed questions. Closed questions, those that can be answered with a simple ‘yes’ or ‘no’ are critical for assessments. And they help the process of assessment speed up without impairing the level of care. However, sometimes a closed question isn’t enough. There are times when leaving the answer open for description or explanation can help provide better care. For instance, ‘Do you smoke?’ might be a simple yes or no answer. But it might be helpful to know ‘Did you ever smoke? If so, what about your family members growing up?’ Questions about overall lifestyle and happiness can also give you insight about the patient that closed questions would stifle.

Make charts with mnemonic devices. Yes, we just spent all this time telling you to listen, feel, and empathize with your patients. And we still recommend all those things. However, you still have to remember the basics of whatever style of care you perform. If you deal with trauma, pain, substance abuse, or other area of healthcare, you likely have a basic set of signs and symptoms that set off red flags and steer the conversational parts of your assessment in different directions. There are many examples of history taking outline documents that are helpful, including this one for alcoholism, and this one for rapid trauma assessment.

If you have a few extra minutes, you can watch this video that defines the process and structure for taking patient histories. As a medical assistant, you are the first line of care for patients and getting an accurate patient history is your responsibility. Taking the time to perfect your craft can literally be the difference between life and death.

Do you have your own tips for taking a patient history to reach the best diagnosis and deliver high quality care? Please share them with us!