DQ 680B 5 Critical Questions to Ask Every Patient
DQ 680B 5 Critical Questions to Ask Every Patient
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
A 50-year old female complains of being waken up at night with a bitter taste in her mouth about four times per week for the past two months. It is interfering with her sleep and she is concerned.
A 48-year old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
A 22-year old female complains of 3 days of watery diarrhea with 7-8 stools per day. She is drinking approx. “3 sodas a day” because she is “trying to not get dehydrated”. Very little other intake because “eating makes me have to go to the bathroom”.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
When your medical practice has a new patient, starting off on the right foot can make a positive difference over the short and long term. Information you collect at the beginning of the patient relationship helps both parties avoid surprises and ensure that medical billing is accurate.
Collecting basic medical history data up front lets clinicians know if there are chronic conditions that need to be addressed, and collecting payment and insurance information lets your claims and billing personnel work efficiently so the revenue cycle doesn’t needlessly slow down. When you have outstanding electronic health record (EHR) software orchestrating the collection and storage of patient information, all these tasks are easier for your staff. Here are 5 questions every medical practice should ask when a new patient arrives.
1. What Are Your Medical and Surgical Histories?
The patient health record will be more complete and valuable if you know whether he or she has ever been hospitalized, treated for a chronic condition, had medical tests, or had surgery.
Even if an adult patient had surgery or some other treatment as a child, it’s important to know about it when creating a treatment plan and delivering healthcare.
2. What Prescription and Non-Prescription Medications Do You Take?
Some people think that over-the-counter medications don’t count, or that herbal supplements don’t matter. Make it clear to new patients that the physician needs to know not only about any prescription medications he or she takes, but also over-the-counter medications, vitamins, and herbal supplements.
It’s ideal if the patient brings prescription bottles to the appointment so the information collected is as accurate as possible.
3. What Allergies Do You Have?
In addition to knowing whether a new patient has seasonal or food allergies, doctors need to know if they have any drug allergies, a latex allergy, or a serious reaction to bee stings, for example. EHRs are terrific for using this information to alert doctors and nurses of potential drug interactions and allergies so allergens can be avoided.
4. What Is Your Smoking, Alcohol, and Illicit Drug Use History?
If you make it clear up front that you take patient confidentiality seriously and protect their information at all times, they’re more likely to be forthright about whether they use tobacco products, drink alcohol regularly, or use (or have used) illicit substances. Answers to these questions can make a difference when it comes to diagnosing and treating health conditions, and reassuring patients of their privacy helps elicit honesty from the start.
5. Have You Served in the Armed Forces?
It’s important to know if a new patient has served in the military, particularly if he or she participated in one or more combat tours. This can help you learn more about physical trauma, potential exposure to toxins, and possible mental health issues like post-traumatic stress disorder, so that diagnosis and treatment options can be tailored to the patient’s needs.
Choosing an EHR Software
If your EHR system harmonizes well with your work processes, it can make things easier on your staff and ultimately on patients as well. Choosing an EHR software can be difficult for medical practices. When making the decision, a practice should consider if the EHR will help with collecting patient information before the patient enters the waiting room. An EHR is more than a software to hold patient data. A top EHR solution will help your practice achieve more accurate medical billing, improve patient engagement and communication, and share patient information with other providers.
Optimizing care requires up-to-date, accurate patient information, and efficient medical billing also depends on complete and accurate data. When your EHR system is a unified platform, claims can be submitted more quickly, be less likely to be rejected because of mistakes, and patient billing can be done expediently.