How to Gather Patient Information for My Medical Office

Opening your own medical office is a tremendous feat, and it leaves many wondering about the clinical technicalities, such as where and how to gather patient information. When it comes to personal health information it is important to understand the Health Insurance Portability and Accountability Act rules about patient disclosure, privacy and confidentiality. HIPAA guidelines offer doctors and medical offices information about legally requesting patient information from other health care entities, as well as how to ensure that HIPAA applies for patients as they fill out information for your medical office.

Instructions

• 1

  Create a medical questionnaire form for new patients. Include all of the health care categories that are beneficial to your office for providing quality care, such as categories for patient medical history, prescription medication list, behavioral health, physical health, substance abuse, family health history, current medical conditions and presenting concerns. Figure out the best way to collect the information on the questionnaire, such as by using check boxes for "yes" or "no," or leaving blank lines for patients to fill in the answers. Be sure to include a statement on the questionnaire that informs patients of the HIPAA privacy practices of your office, and that the information recorded on the questionnaire is kept confidential.

• 2

  Develop a policy for providing the medical questionnaire to all new patients. The policy must include information about when the questionnaire is distributed to patients, where it is kept after the patients complete it and who has access to it.

• 3

  Ask all new patients to fill out a contact sheet. They must provide your medical office with their home number and home address, as well as with an email address, work phone number and emergency contact. Another form should be distributed to new patients to collect their health insurance information.

• 4

  Contact a patient's former health clinic for additional information. If you are receiving a new patient as a referral or a transfer from another doctor, it is legal for doctors to exchange information because it is in the best interest for the patient to receive quality, and accurate, treatment. For instance, if a patient is on a particular medication, but forgets to inform the new doctor of it, the doctor can, without knowing it, write a prescription for a new medication that should not be mixed with the medicine the patient is already taking. When two doctors correspond about a patient it helps to keep the patient in good hands. As the doctor or medical office owner, request a transfer of the patient's medical files.

• 5

  Get in touch with the hospital if your patient was recently discharged from a hospital visit. You will need the information from the hospital to know what the patient went in for, how he was treated, what medications he was given and what the status is now.

• 6

  Talk to your patient. Ask her questions in an interview format and collect the information you need from her in person. Write down what she tells you so you can keep the information in her medical record.