How to Take Patient Histories

One of the many numerous responsibilities taught in an online Medical Assistant school is to keep track and record patient histories. Now you may be asking yourself, what exactly is patient histories? But that question only lasts about a minute before you realize that it is as the name suggests – the history of any given patient. These histories include records of the patients’ past, any and every previous illness, any past surgeries and medical procedures, and former vaccinations as well.

When you’re working in a medical facility and a new patient comes in for a visit, as a medical assistant you will be responsible for creating new records for these patients. For patients who become regulars at the clinic or facility you work for, however, you only have to refresh/update what information is already on record. For instance, you would write about any new illnesses that have occurred, surgeries that have come to pass, and what medication they have recently taken – whether it was prescribed or over the counter.

Here are few things medical assistants do when recording a patient’s history:

  1. Be warm and inviting – in order to record a patients history you have to engage in conversation with them. This can be difficult since with new patients you’ll be a new face to them. Be warm and inviting and greet them in a friendly manner. If they warm up to you they will give you the kind of information you need with ease.
  2. Get down to the nitty gritty – After a patient has warmed up to you it’s time to ask for details. You have to really get a lot of detailed information from them. A lot of it will not only help you with record keeping, but will help the doctor as well before even coming in to make an analysis.

Electronic Health Records Infographic from ONC


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