Reference no: EM133554324

Case Study: Introduce yourself to the new patient and confirm his or her identity, using two identifiers. Your interaction with the patient should be welcoming and warm. Use gentle eye contact and positive body language to put the patient at ease. Explain the importance of obtaining the patient's personal and medical history. If you are using a paper medical record, be sure to use a dark blue or black ink pen to fill in the information. Ask the patient the questions on the facility's patient history screen. Encourage the patient to provide comprehensive information while also keeping the patient on topic. Ask each question clearly, and clarify that the patient understands what you are asking. Confirm the patient's answers as necessary. Ask about allergies and any activities that could affect health, such as smoking or alcohol use. Be specific when documenting the information, providing frequency, amount and duration of activities. Recheck the patient history screen to be sure all parts are complete. Make sure numbers, dates, spelling, and other information are accurate. Electronic records are automatically dated and stamped with the name of the user entering the information.

Questions:

1.Taking a medical history on a patient is a routine task. Describe what is involved with this and what the purpose is.

2.Describe when and how a medical history is obtained.After the history is completed, the provider will perform a review of systems (ROS). Describe what this is and what it entails.

3.After the history is completed, the provider will perform a review of systems (ROS). Describe what this is and what it entails.