The Art of Communication: Taking Patient Histories as a Medical Assistant

Patient interaction is an enormous part of being a medical assistant. While your typical day-to-day at the hospital may feel quite hectic at times, it’s important to always prioritize patient care and communication. As a medical assistant, creating patient history forms is one of the cornerstones of your job. These histories must be thorough and include information about any new illnesses, surgeries, or medications that may affect the patient’s treatment course.

In the midst of activity, we often forget the basic principles of good communication. However, in this profession, asking people for their medical histories effectively can make a big difference in their health care outcome. Below are some helpful tips for establishing a good rapport with patients during their visit to your medical center. As you progress in your career, you may find these tips more and more helpful in maintaining good patient relationships.

1. Establish a Rapport

A little small talk can go a long way in “breaking the ice” with patients. Though it may sound obvious, but personal introductions are often forgotten during the course of an average medical assistant’s workday. Remember to ask the patient about his/her day, ask them if they’re feeling any pain, and always explain what you’re about to do clearly and why you’re doing it. Establishing trust can help you and your employers provide better patient care and save lives in the long run.

2. Follow Protocol

Most medical centers feature standard history forms that need to be filled out for each new patient. As a medical assistant, you must always remember to fill out the form you’re given completely and error-free. Don’t jump over sections or assume you know what the patient is going to say.

3. Be Thorough

In some cases, patients may not share their full histories. This can be due to simply forgetting about an aspect of treatment that they have received before. If a patient has had previous illnesses or surgeries, ask for dates and specifics. If the patient is taking prescription medications, over-the-counter drugs or dietary supplements, ask for dosages and frequencies. That being said, don’t press the patient too hard! The important thing is to always help them remain calm and comfortable.

4. Don’t Judge!

While discussing a patient’s medical, you’ll be covering territory that is often personal, intimate, and perhaps even embarrassing! This is especially the case when discussing sexual issues and recreational drug use. In order to get clear and complete information, you must always aim to stay composed, attentive, sympathetic, and supportive. Laughing, cringing, gagging or otherwise conveying disdain through other sounds or body language can lead to getting incomplete information.

5. Don’t Offer Advice!

Through the course of conversation, patients may sometimes as for your medical opinion regarding their conditions or treatments. Though your medical training may have prepared you with the information needed to provide a response, doing so can make you liable. On matters beyond the scope of your medical office duties, your best default response should be, “the doctor can answer that for you.” This not only protects you, but also prevents the patients from having false expectations of the doctor that will attend to them.