Patient Encounter Structure
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- Audra Doyle
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1 Checking Doorway Information Full Name Age Sex Chief Complaint Vital Signs Blood Pressure Body Temperature Respiratory Rate Heart Rate Patient Encounter Structure 1. Greeting & Introduction 2. Chief Complaint ( ICE & DNA ) 3. History of Present Illness ( OPQRST ) 4. Risk Factors ( PAM HITS FOSS ) 5. Summary 6. Physical Examination 7. Diagnostic Impression 8. Follow-up Plan 9. Counseling 10. Q&A 1
2 Patient Encounter Basic Expressions 1. Greeting & Introduction Greeting Hello. Confirming your patient s full name Are you Mr John Smith? Are you Ms Jane Smith? Introducing your name and title My name is Takayuki Oshimi, one of the student doctors at this hospital. Describing your role I ll be helping you today. Asking for a permission Would that be all right with you? History Taking 2. Chief Complaint ( ICE & DNA ) 3. History of Present Illness ( OPQRST ) 4. Risk Factors ( PAM HITS FOSS ) 2. Chief Complaint ( ICE & DNA ) How can I help you today? Could you tell me more about the (chief complaint)? Ideas Do you have any ideas about it yourself? Concerns Is there anything particular that you are concerned about? Expectations What are your expectations about this visit today? Day How does it affect your day? Night How does it affect your night? Activities How does it affect your activities of daily living? 2
3 3. History of Present Illness ( OPQRST ) Onset When did the (symptom) start? When did you first notice the (symptom)? Did it start suddenly or gradually? Provoking & Palliating Factors What makes the pain worse? What makes the pain better? Quality Could you describe the (symptom)? What type of pain is it? Is the pain sharp or dull? Region & Radiation Could you show me where it hurts? Does the pain move anywhere else? Severity On a scale of one to ten, ten being the worst pain you can imagine, how severe is the pain now? How severe was it when it started? Symptoms (relevant to differential diagnosis) Do you have (symptom: noun)? Do you feel (symptom: adjective)? Have you noticed any change in (habit)? Has anyone you know noticed any change in your (appearance)? Have you been (verb)ing more than usual? Sometimes patients with (chief complaint) have (symptom: noun). Has this happened to you? Timing How long/many hours/many days/many weeks have you been having the (symptom)? Does the (symptom) come and go or do you have it all the time? 3
4 4. Risk Factors ( PAM HITS FOSS ) Previous presence of the same symptom Have you ever had the same symptom before? Was it exactly the same as now? Allergies (medications & food) Are you allergic to any medications/food/anything else? What happened when you got the allergy? Medications (prescription drug, OTC, and nutritional supplements) Are you currently on any medications/supplements? Do you take it as the doctor prescribed? HITS (Past Medical History) Hospitalization Have you ever been hospitalized? Illness Have you ever had any serious health problems in the past? Trauma Have you ever had any major injuries in the past? Surgery Have you ever had any surgeries/operations in the past? Family History Do any health problems run in your family? Does anyone in your family have (specific disease)? Does anyone in your family have similar symptoms? Full Transitions* Necessary when asking about ObGyn, Sexual History, and Social History Introducing the new topic I will now be asking you some questions about your sexual life. Reassuring the patient These are some routine questions I ask all my patients. Provide confidentiality Any information you provide will be completely confidential. Obtain permission Would that be all right with you? 4
5 4. Risk Factors ( PAM HITS FOSS ) (cont d) Obstetrics & Gynecology (Full Transitions* required) When was your last monthly period? Is there any possibility that you might be pregnant? Have you ever been pregnant in the past? Sexual History (Full Transitions* required) Are you currently sexually active? How many sexual partners have you had in the past 12 months? Do you have sexual intercourse with men, women, or both? Social History: SODA (Full Transitions* required) Smoking Do you smoke? How many cigarettes do you smoke per day? How long have you been smoking? Occupation What is your occupation? How are things at home? Drugs Have you ever used any recreational drugs in the past? Which drugs (uppers/downers/psychedelics) do/did you use? Alcohol Do you drink alcohol? How many drinks do you have a week? CAGE Questionnaire* *If the patient reports more than 14 standard drinks per week (7-10 drinks per week for female patients) Cut down Have you ever felt you should CUT DOWN on your alcohol consumption? Annoyed Have you ever felt ANNOYED when someone criticizes your drinking habit? Guilty Have you ever felt GUILTY about your drinking habit? Eye opener Have you ever had a drink first thing in the morning? (EYE OPENER) 5
6 5. Summary Let me summarize your story. You have come to this hospital because of (chief complaint). You also have (ideas/concerns/expectations). Is that correct? 6. Physical Examination Simple Transition Mr Smith, now I ve finished taking your medical history. We will now begin with the physical exam. Hand Washing Before we start, I will wash my hands. WHAT: Explain the examination. Mr Smith, I am going to listen to your heart using this device. I am going to I will now I would like to I need to Commonly used verbs to check: I am going to check your reflexes. to examine: I need to examine your belly. to look: I will now look at the back of your eyes. to brush: I am going to brush your face using a cotton ball. to press: I am going to press different parts of your belly. to place: I will now place this device behind your ear. to put: I will now put this device behind your ear. to move: I would like to move your arms. to tap: I will now tap just below your kneecaps with this device. to listen: I would like to listen to your heart. WHY: Justify the examination. to see if everything is fine. to find our why you have this symptom to check if everything is normal to see if there is a problem to look for any sign of infection to make sure that everything is OK INSTRUCTIONS: Give instructions about patient s role Could you breathe quietly, please? EXPECTATIONS: Explain about possible pain and discomfort. Please let me know if you have any (pain or) discomfort. OK? 6
7 7. Diagnostic Impression Medical Exchange & Discovery 2017: Clinical English Course Mr Smith, let s discuss some possible diagnoses for your case. After taking your history, there are several possibilities. One of them is a problem called (most likely but least serious diagnosis), which is a common disease that can produce symptoms like the ones you have. We still need to run some tests to make sure it is not something else. We need to also check for (more serious diagnosis),and also we need to check for (most serious diagnosis). 8. Follow-up Plan Mr Smith, we will be running some tests to confirm what is causing your symptoms. I am ordering some blood tests to see if there is any sign of (condition). I would also like to get a (imaging test) of your (body part) to see if your (body part) is normal. 9. Counseling You should quit (forceful) I usually recommend all my patients quit (gentle) Mr Smith, you mentioned during the history that you are a smoker, is that correct? I usually recommend all my patients quit smoking in order to avoid health problems. Have you ever considered quitting? If you want, I can introduce you to our support group here at the hospital. We have an excellent team that can help you quit smoking. 7
8 10. Q&A Medical Exchange & Discovery 2017: Clinical English Course Mr Smith, do you have any questions for me? Challenging Question 1: I have been waiting here for 3 hours! Why have you kept me waiting so long? Challenging Question 2: I can t afford the cost of staying in the hospital. I have no insurance. Can you give me something to relieve the pain? Challenging Question 3: My father had lung cancer. What is the possibility that I will have lung cancer as well? 5-Step Strategy for Challenging Questions Step 1: Express your interest in your patient s concern Could you tell me more about your concern? Step 2: Restate your patient s concern to express your understanding I understand that your main concern is I understand that you feel frustrated by I understand your concern about Step 3: Reassure your patient using the PEARLS technique Partnership: Let s deal with this together. Empathy: That sounds hard. Apology: I m sorry this happened to you. Respect: You obviously have worked hard on this. Legitimization: Anyone would be upset by this situation. Support: I ll be here when you need me. Step 4: Give your honest but diplomatic answer to the question I understand that you are concerned about medical costs, but your life will be in danger if you don t have surgery. Let our social workers help you with the cost issues. I cannot answer that question at this time. Let s wait for the test results and discuss the issue when we have more information. Step 5: Ask if your patient has more questions Does that answer your question? Do you have any other questions? 8
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