Patient History

Medical Assisting

This module provides knowledge on the medical assistant's role in taking patient history.

A patient history is a record of a patient's medical past, including previous illnesses, surgeries, and vaccinations, as well as information about the patient's current state of health. A key responsibility of a medical assistant is to take patient history. In this module, students will learn how to obtain and document needed information for patient history, and how to use therapeutic communication techniques to gather the needed information.

You’ll learn

the type of information included in patient history
the steps for how to obtain and document patient history
how to document a patient's record using the SOAP format
how to identify barriers to communication
much more (see Content Details for more specific information)

Introduction

Step 1 - Preparation

Step 1.1 - Equipment preparation

Step 1.2 - Medical assistant preparation

Step 1.3 - Patient preparation

Step 2 - Procedure

Step 3 - Complete the documentation

Demonstrate therapeutic communication feedback techniques to obtain information when gathering patient history.
Obtain and document patient history.
Respond to nonverbal communication while iterating with the patient.
Demonstrate correct documentation of the patient's record using the SOAP format.

The SIMTICS modules are all easy to use and web-based. This means they are available at any time as long as the learner has an internet connection. No special hardware or other equipment is required, other than a computer mouse for use in the simulations. Each of the SIMTICS modules covers one specific procedure or topic in detail. Each module contains:

an online simulation (available in Learn and Test modes)
descriptive text, which explains exactly how to perform that particular procedure including key terms and hyperlinks to references
2D images and a 3D model of applied anatomy for that particular topic
a step by step video demonstration by an expert
a quiz
a personal logbook that keeps track of all the modules the learner has studied and how long