09-30-2004, 10:47 AM
doc2005
TIPS:
· Don?t forget to knock before entering the room.
· If the patient is not in terrible pain try to introduce yourself with a handshake.
· Always keep eye contact
· be compassionate and PATIENT
· smile whenever appropriate and NEVER interrupt the patient or try to hurry him!
· Never talk to the patient not facing him except the physical exam part.
· Wash your hands BEFORE the physical exam.
· Let the patient know whatever you are going to do in advance.
· NEVER ignore even the most ridiculous or simplest question or concern raised by the
patient.
· Don?t be afraid to talk about the weather or patient?s wedding etc. to make him relax.
Sometimes (especially with difficult patients) that?s the point of the encounter.
· Patient?s modesty should always be your concern. Always cover parts of the body
you?re not examining. Explain why some maneuvers are necessary etc.
· Always help your patient and show concern about his safety and comfort (leg support,
level of light in the room, helping him/her getting up etc.)
· Finally explain your findings and plan of action very shortly, letting the patient know
that it?s a pleasure and an honor helping him and you will be very thorough in taking
care of him. If the patient doesn?t have any questions say good bay and once again
assure patient you will do whatever possible to help him without giving false
reassurance.
GENERAL SCRIPT
Ms. X? Good morning.
My name is Dr. Y It?s nice to meet you. I?ll be taking care of you today. I?d like to ask you few questions, so let?s get started, OK?
CC:
Ms X, what made you want to see a doctor today?
HPI: (following questions are related to pain as a major complain. In the case of other complains, modify the questions according to symptoms. For example: in the case of diarrhea ask about sick contacts, travel story etc.)
· Please show me exactly where the pain is.
· Does it ever move anywhere else?
· How would you describe the pain? (sharp, stabbing, vague, burning, dull, etc.)
· If 10 is the worst pain you?ve ever had, where is this pain on a scale of 1 to 10?
· Have you ever had this before?
· When did it start?
· How often do you get it?
· Do you have idea of what might have brought this on?
· Has this pain changed any over time? How?
· Does anything make it worse?
· Does anything make it better?
· Do you have any other symptoms, like_____________? How about_________? __________?
So, Ms X, Let me summarize what you?ve told me so far, OK?
________________________________________________________Is that right?
PMH:
OK Ms X, now I need to ask you some questions about your health in general.
· Have you ever had any serious illness?
· How about ________? _____________? _________________?
· Have you ever had any accidents or injuries?
· Have you ever had surgery?
· Have you ever had to stay in hospital otherwise?
· Are you allergic to anything? Drugs? Food? Anything else?
· Do you have any pets or plants?
· Ms Cooke, are you taking any prescribed medications?
· What? How much? For how long?
· Do you have it now? May I see it?
· How about OTC (over-the-counter) products?
· Have there been any recent changes in your urinary habits?
· Have you had any changes in your bowel habits lately?
· Has your weight changed recently?
· Have you noticed any changes in your sleeping pattern?
OB & GYN Hx:
Ms X, now I?d like to ask you some questions about your period cycle and eventual pregnancies. Is it OK with you?
· At what age did you start your period?
· When was your last menstrual period (LMP)?
· Do you have your periods regularly (every month)?
· How many days is in your cycle?
· On a heavy day, how many pads or tampons do you use?
· Do you have any problems with PMS?
· Have you
TIPS:
· Don?t forget to knock before entering the room.
· If the patient is not in terrible pain try to introduce yourself with a handshake.
· Always keep eye contact
· be compassionate and PATIENT
· smile whenever appropriate and NEVER interrupt the patient or try to hurry him!
· Never talk to the patient not facing him except the physical exam part.
· Wash your hands BEFORE the physical exam.
· Let the patient know whatever you are going to do in advance.
· NEVER ignore even the most ridiculous or simplest question or concern raised by the
patient.
· Don?t be afraid to talk about the weather or patient?s wedding etc. to make him relax.
Sometimes (especially with difficult patients) that?s the point of the encounter.
· Patient?s modesty should always be your concern. Always cover parts of the body
you?re not examining. Explain why some maneuvers are necessary etc.
· Always help your patient and show concern about his safety and comfort (leg support,
level of light in the room, helping him/her getting up etc.)
· Finally explain your findings and plan of action very shortly, letting the patient know
that it?s a pleasure and an honor helping him and you will be very thorough in taking
care of him. If the patient doesn?t have any questions say good bay and once again
assure patient you will do whatever possible to help him without giving false
reassurance.
GENERAL SCRIPT
Ms. X? Good morning.
My name is Dr. Y It?s nice to meet you. I?ll be taking care of you today. I?d like to ask you few questions, so let?s get started, OK?
CC:
Ms X, what made you want to see a doctor today?
HPI: (following questions are related to pain as a major complain. In the case of other complains, modify the questions according to symptoms. For example: in the case of diarrhea ask about sick contacts, travel story etc.)
· Please show me exactly where the pain is.
· Does it ever move anywhere else?
· How would you describe the pain? (sharp, stabbing, vague, burning, dull, etc.)
· If 10 is the worst pain you?ve ever had, where is this pain on a scale of 1 to 10?
· Have you ever had this before?
· When did it start?
· How often do you get it?
· Do you have idea of what might have brought this on?
· Has this pain changed any over time? How?
· Does anything make it worse?
· Does anything make it better?
· Do you have any other symptoms, like_____________? How about_________? __________?
So, Ms X, Let me summarize what you?ve told me so far, OK?
________________________________________________________Is that right?
PMH:
OK Ms X, now I need to ask you some questions about your health in general.
· Have you ever had any serious illness?
· How about ________? _____________? _________________?
· Have you ever had any accidents or injuries?
· Have you ever had surgery?
· Have you ever had to stay in hospital otherwise?
· Are you allergic to anything? Drugs? Food? Anything else?
· Do you have any pets or plants?
· Ms Cooke, are you taking any prescribed medications?
· What? How much? For how long?
· Do you have it now? May I see it?
· How about OTC (over-the-counter) products?
· Have there been any recent changes in your urinary habits?
· Have you had any changes in your bowel habits lately?
· Has your weight changed recently?
· Have you noticed any changes in your sleeping pattern?
OB & GYN Hx:
Ms X, now I?d like to ask you some questions about your period cycle and eventual pregnancies. Is it OK with you?
· At what age did you start your period?
· When was your last menstrual period (LMP)?
· Do you have your periods regularly (every month)?
· How many days is in your cycle?
· On a heavy day, how many pads or tampons do you use?
· Do you have any problems with PMS?
· Have you