Patient intake is where clinical care begins. Everything that happens in that first 10-15 minutes sets the foundation for the provider visit. A thorough, organized intake gives the provider accurate information. A rushed or incomplete intake creates gaps that can affect patient safety. Medical assistants own this process in most outpatient settings.
The Intake Workflow
The intake workflow follows a consistent sequence. Deviating from the sequence creates inefficiency and increases the chance of missing something.
Step 1: Greeting the Patient
Introduce yourself by name and role. "Hi, I'm Jordan, one of the medical assistants. I'll be getting you checked in today." This sets expectations and establishes rapport. Make eye contact. In a busy waiting room, step out and call the patient rather than shouting a name across the space.
Be attentive to the patient's demeanor from the first moment. A patient who is in obvious pain, appears confused, or looks acutely ill needs to be triaged immediately rather than following the routine intake sequence. Clinical judgment starts here.
Step 2: Verifying Identity
Confirm two patient identifiers — full name and date of birth. Do not just confirm with "Are you Jane Smith?" — ask the patient to state their name and date of birth. This prevents mix-ups in busy practices, especially with patients who have similar names. Verify the match against the chart, appointment, and any wristband in hospital-affiliated settings.
Step 3: Updating Demographics
Confirm or update: address, phone number, emergency contact, insurance information, preferred pharmacy. Ask whether any information has changed since the last visit rather than re-entering everything from scratch. In the EHR, flag updates for the front desk or update them per your facility's workflow. Outdated contact information causes problems with lab results, prescription routing, and follow-up calls.
Step 4: Reviewing and Reconciling Medications
Ask the patient to list all medications they are currently taking, including prescription medications, OTC medications, vitamins, and supplements. Compare this against the medication list in the chart. Flag any discrepancies — new medications not in the chart, medications on the chart that the patient is no longer taking, or dose changes.
Ask specifically: "Are you taking anything new since your last visit? Any vitamins or supplements?" Many patients do not consider OTC products as medications. This question can surface interactions that would otherwise be missed.
Document the reconciled medication list in the EHR, including dose and frequency for each medication where available. The provider reviews and confirms this list during the visit.
Step 5: Allergy Documentation
Ask about allergies at every visit. Do not assume the chart is current. Patients develop new allergies and may have had reactions since their last visit.
For each reported allergy, document:
- The allergen (specific drug name, food, environmental trigger)
- Type of reaction (hives, anaphylaxis, rash, nausea, etc.)
- Severity
Distinguish between a true allergic reaction and a side effect or intolerance. A patient who had nausea from a medication has an intolerance — not the same as anaphylaxis. Both are worth documenting, but they have different clinical implications. Do not use vague entries like "penicillin — allergy." Document the reaction. If the patient cannot recall the reaction, note that.
Mark allergies clearly in the EHR using the designated allergy field — not a free-text note that a provider might miss.
Step 6: Chief Complaint
The chief complaint is the reason the patient is here today, in their own words. Ask: "What brings you in today?" or "What can we help you with today?" Document it in quotes if possible — "patient presents complaining of sore throat for 3 days" rather than "sore throat." This preserves the patient's perspective and the context.
The chief complaint is not the same as the history of present illness (HPI) — that is documented by the provider. Your job is to capture the reason for the visit clearly enough that the provider walks in knowing what to expect.
If the patient has multiple concerns, note all of them. Some practices have a policy of addressing only one concern per visit; others are more flexible. Either way, capture what the patient said they came in for.
Step 7: Vital Signs
Vital signs are objective measurements of basic body functions. Take them accurately and in the right order. Standard vitals in the outpatient setting include:
- Temperature: Normal 97.8-99°F (36.5-37.2°C). Route (oral, tympanic, temporal, axillary, rectal) affects normal ranges and accuracy. Rectal is most accurate but used primarily in pediatrics. Document the route taken.
- Pulse: Normal 60-100 bpm at rest. Note rate and regularity. Radial pulse is standard. Apical pulse (at the apex of the heart, left 5th intercostal space, midclavicular line) is used when radial is weak or irregular, and for infants.
- Respirations: Normal 12-20 breaths per minute in adults. Count for a full 30 or 60 seconds. Do not tell the patient you are counting respirations — it makes them breathe consciously and alters the count. Count while appearing to still take the pulse.
- Blood pressure: Normal less than 120/80 mmHg. Use appropriate cuff size — a cuff too small reads falsely high, too large reads falsely low. Patient should be seated, feet flat, arm supported at heart level, no talking during measurement. Take in both arms on initial visits. Wait at least 5 minutes after the patient is seated before taking the reading.
- Oxygen saturation (SpO2): Normal 95-100%. Applied to a fingertip with a pulse oximeter. Nail polish, poor perfusion, and cold extremities can affect accuracy.
- Height and weight: Measured at new patient visits and periodically after. Weight is often needed for medication dosing, especially in pediatrics. BMI is calculated from height and weight.
Document vital signs accurately. If a vital sign is out of range, do not dismiss it or retake it hoping for a better number. Retake once to confirm, then report it to the provider.
Step 8: Pain Assessment
If the patient's chief complaint involves pain, assess and document pain using a standardized tool.
- Numeric Rating Scale (NRS): 0-10 scale. "On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?" Simple and widely used in adults.
- Wong-Baker FACES Scale: Visual scale with facial expressions numbered 0-10. Used for children and patients who struggle with numeric scales.
- FLACC Scale: Behavioral observation scale for infants and non-verbal patients (Face, Legs, Activity, Cry, Consolability).
Also document pain characteristics: location, quality (sharp, dull, burning, cramping), duration, what makes it better or worse, and whether it radiates. Use the OLDCART or PQRST mnemonic if your facility uses one.
Step 9: Preparing the Patient for the Provider
Depending on the visit type and provider preference:
- Provide a gown if an examination requiring disrobing is anticipated
- Explain which areas the patient should expose and which to leave covered
- Position the patient appropriately — supine for full exams, seated for most routine visits
- Ensure needed equipment is in the room (otoscope, ophthalmoscope, reflex hammer, etc.)
- Tell the patient the provider will be in shortly
Step 10: Documentation in the EHR
Document intake findings before leaving the room, or immediately after. Delayed documentation increases errors. In the EHR, use the correct fields for each type of information — medications in the medication module, allergies in the allergy module, vitals in the vital signs section. Free-text notes are for information that does not fit elsewhere.
Write objectively. Document what the patient said and what you measured — not your interpretation or assumptions. "Patient rates pain 7/10 in the right lower quadrant, describes it as sharp, worse with movement, onset 12 hours ago" is better than "patient has abdominal pain."