Step-by-Step Guide to Taking Medical Histories
Learn the procedures, steps, risks, and requirements for taking medical histories.
A medical history acts as a record of each patient’s health. It may include information about illnesses, surgeries, allergies, or immunizations. It covers a person’s personal history and that of their family as well. Your medical history is like a fingerprint. It’s unique and serves an important function. By taking a medical history properly, healthcare professionals can better understand the state of a patient’s health. Mastering this skill will lead to a much better experience for healthcare practitioners and their patients.
As you can see, medical histories are essential for most medical treatments. This fundamental skill may not sound like an exciting prospect for new healthcare professionals, but it is perhaps the most critical task they will need to learn. Many Medical Assistants are trained to take medical histories in a physician’s office. In addition, they often review medical records before the physician arrives.
This article provides an in-depth guide on the art and science of taking medical histories, one of the most important healthcare procedures for medical staff.
(Click here to see our full list of Medical Assisting duties and responsibilities).
Medical Histories Definition
What are Medical Histories?
Medical histories are records of information about a patient’s health. For example, medical history may include information on allergies, illnesses, immunizations, surgeries, and results of physical exams or other tests. In addition, it may note medicines taken as well as regular health habits.
What is the Purpose of Medical Histories?
The ultimate goal of acquiring a patient’s medical history is to understand the state of their health. In addition, medical records can help healthcare professionals determine if the patient’s history is related to any acute complaints. In other words, medical histories can contribute to an eventual diagnosis. Some physicians investigate much like a detective would so that they can come to the correct conclusion.
How Long Does it Take to Get a Medical History?
Most medical histories can be recorded in about ten minutes or less. For the patient to obtain a copy, providers typically have anywhere from 30 to 60 days to process the request. However, some facilities may provide their patients with a copy in five to ten days.
Who Can Take Medical Histories?
Doctors, nurses, and various other healthcare professionals can take medical histories. In addition, physician assistants often take medical histories as well. Medical records and health information specialists also meet with other healthcare workers to clarify diagnoses or seek more information.
Under their scope of practice, Medical Assistants will often take medical histories in a physician’s office. They lead patients to exam rooms, measure vital signs, and review medical histories before the physician arrives.
(Click here to learn how to become a Medical Assistant).
Training Requirements for Medical Histories
Requirements for taking medical histories can vary and depend on your location or profession. Aspiring healthcare professionals will usually receive this training through their educational programs.
At Unitek College, we offer a Medical Assisting program that could give you a strong advantage when applying to nursing school or other healthcare positions. Our courses include topics like taking vital signs, medical office administration, medical law, pharmacology, diagnostic imaging, and more.
Taking Medical Histories Procedure
With these steps, you can start to learn more about the process of taking medical histories. Of course, like most skills, medical histories require time and practice to get them right. Remember to follow your facility’s rules and ask for help whenever necessary.
Medical History Steps
Here are some of the general guidelines that healthcare professionals should follow when taking medical histories:
- First, greet the patient by name. Don’t forget to introduce yourself, too!
- Ask them a friendly but pertinent question, such as: “What brings you in today?” The goal is to obtain information about the presenting complaint.
- Remember to collect past medical and surgical history. This should include any allergies or medications that they’re currently taking.
- Inquire after the patient’s family history.
- Ask about their social history and lifestyle, such as what they do for a living, smoking or alcohol habits, etc.
- Complete the patient’s medical history by reviewing what they told you. Repeat back important points so that the patient can correct any inconsistencies.
- Conclude this part of their appointment by asking if they have any questions for you. Afterward, thank them for their time and tell them that the doctor will arrive soon.
Necessary Equipment for Medical Histories
Typically, the suggested supplies for medical histories include but are not limited to the following items:
- Clinical Thermometer
- Stethoscope
- Blood Pressure Devices
- Penlights
- Heart Rate Monitors
- Pulse Oximeters
- Paperwork
- Clipboard
- Computer
Potential Risks or Complications of Medical Histories
It’s vital that you correctly record a patient’s medical history. For instance, if you do not include a patient’s allergy, this could have disastrous or potentially fatal consequences down the line. While taking a medical history might sound mundane, it’s actually a critical component of the patient’s visit.
Additionally, healthcare providers must remain neutral. This attitude particularly applies to sensitive topics. If a patient feels judged or uncomfortable, they may not provide you with accurate information. Always remember to act understanding and empathetic. Avoid using medical terms that could create confusion. Put yourself in the patient’s shoes.
Pro Tips for Mastering the Art of Medical Histories
Here are some medical history tips that may assist you in the future.
- Be warm and attentive to the patient: You’ve probably heard the saying, “first impressions matter.” This is because they can set the course of a meeting, appointment, etc. Start by introducing yourself and offering a friendly smile. Offer a pillow or blanket if the patient needs one. It would be best to sit in a chair to be at eye level with the patient. These seemingly small gestures tell the patient that they’re important and you have time to hear them.
- Establish a rapport with your patient: When it comes to taking a patient’s history, you want it to be a conversation, not an interrogation. You must establish trust and respect so that they will feel comfortable answering your questions. You can achieve this by making small talk, asking their preferred name, inquiring what they do for work, etc.
- Make sure the patient feels heard: According to Elie Matar, a landmark study found that interrupting a patient early on and quickly reverting to closed questioning often caused the patient to volunteer less information. Remember: Patients want to feel heard. By letting them fully voice their concerns without interruptions, you are showing them that they matter, and you will take their concerns seriously.
- Use a tried-and-true framework for your questions: When you’re recording a patient’s history, there’s quite a bit of information to acquire in a relatively short amount of time. A set structure could keep the conversation on track and make sure you’ve covered all your bases. Check to see if your employer has a list of questions they’d like you to ask.
- Some questions that might get missed include ethnicity, travel history, developmental history, and pregnancy and fertility. If the context is appropriate, it can be very beneficial to ask questions on these topics.
- Be aware of your biases so you can overcome them: Some common biases that healthcare professionals may have include the following:
- Overconfidence bias—You overestimate your abilities.
- Confirmation bias—You interpret information in a way that supports your prior beliefs.
- Availability bias—You start to see things that easily come to mind everywhere you look. Basically, you see what you want to see rather than what is.
- Visceral bias—You let positive or negative feelings toward a patient influence your decisions.
- Study your patient: Although you may not realize it at first, some patients will relay critical information through their body language. So, watch them closely; even a slight change in eye contact or inflection in their voice may offer a clue. They could potentially hint to depression, suicidal thoughts, abuse, or another condition.
- Always ensure accuracy: Once you have finished taking a patient’s medical history, you should have a detailed and complete record. In summation of our earlier points, here are some techniques you can use to improve accuracy.
- Try not to interrupt your patient when they speak
- Prompt them by presenting specific examples of conditions or medications in case they forget something
- Repeat their answers aloud to ensure they’re correct
- Learn about your patient’s lifestyle and daily habits to better understand their life, any recent or significant events, etc.
- Remember the importance of medical history: It’s not an exaggeration to call a medical history one of the most important and powerful diagnostic tools at your disposal. This applies even more now, with greater rates of telehealth and virtual appointments. The correct information is everything when it comes to your patient’s health.
Why Should Medical Assistants Learn How to Take Medical Histories?
Although most facilities employ nurses and other healthcare professionals, it can be very beneficial for Medical Assistants to learn how to take medical histories. This is because nurses may not always be available in smaller settings or even larger ones like hospitals.
While medical histories aren’t always a job requirement for MAs, they are valuable skills that can lead to more significant opportunities. Therefore, it would be advantageous for MAs or aspiring Medical Assistants to pursue the proper training. Once they are prepared to take and review medical histories, an MA could become more indispensable to their employer and possibly gain greater responsibilities.
Start Your Career in Medical Assisting
The ability to take medical histories is an essential skill that aspiring Medical Assistants should learn for their careers. It’s also an essential medical practice for most healthcare professions, proper diagnoses, treatment options, etc.
Think about it: Medical histories provide physicians with a better understanding of a patient’s health. It can serve as a blueprint, helping them to identify patterns, make more effective decisions, and offer better overall care. It is absolutely vital that MAs record accurate medical histories.
If you’re feeling inspired and want to pursue a career in medicine, Unitek College offers various healthcare programs, such as our Medical Assisting program.
Contact us today to learn more about our programs and tuition assistance options. Take the first step toward a rewarding future in healthcare!
