How To Take Better Patient Histories?

  • Medical Assistant
  • March 12, 2024
  • 4 min read
A female Medical Assistant taking patient history

Patient records are a vital part of modern healthcare, providing an invaluable record of the patient’s medical history. As a medical assistant, one of your responsibilities will be to create or update patient histories, recording previous illnesses, surgeries, and vaccinations. Recording patient histories is normally a straightforward process, generally using a standardized form, but there are always ways to improve that process, making things quicker and easier for both you and the patient. Here are five things you can do to take better patient histories.

How To Take Better Patient Histories?

1. Build a rapport

The best way to make things easier for both you and the patient, when taking their medical history, is to build up a rapport with them. Open communication puts people at ease and taking the time for a little small talk can help your patients overcome any unease they are feeling and provide you with the answers you need. Ironically, taking the extra time to break the ice can make things faster in the long run, opening a line of communication that enables the quick and efficient exchange of information.

2. Remember the details

Healthcare practices are busy places, and as a staff member, you might not have a huge amount of time to collect information from your patient. While this isn’t the ideal situation, it is the reality of a busy workplace. Although you might have a dozen other things to do, it is important to remember that the details of a patient’s history are incredibly important. Information on recent surgery dates, medications, and allergies are all vital to providing a patient with the best healthcare possible.

3Follow the procedure

There is every possibility that the patient record form you will be using will be a standardized document with a particular procedure for filling it in. It’s important that you stick to this procedure. Standardized forms allow back office staff to quickly and efficiently process information, not sticking to procedures could cause errors and delays for the administrative staff.

4Listen, don’t talk

Patients will often want to discuss medical matters with you while you are taking their information and it can be hard not to attempt to put them at ease but address their concerns. Rather than offering opinions, it is best to offer neutral responses, acknowledging their concerns but advising them that it would be best to address them with their doctor.

5Maintain formality

Most people get into healthcare because they want to care for others and this can lead to you adopting an informal approach to communication in order to reassure people. While this is a skill that can be very useful in certain situations, there are times when a little distance between you and the patient can be helpful. The information you gather from your patient might be sensitive or embarrassing. Maintaining a formal manner when collecting it helps remove any perceived element of judgment or ridicule that your patient might be worried about.

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Corey Del Pino
Dean Of Clinical Programs

Born and raised in Los Angeles, Corey Del Pino attended Northern Arizona University after high school and graduated with a Bachelor’s of Science in Biology with a Chemistry Minor in 2012. After attending Mohave Community College and earning her Medical…Read Full Bio