190x Filetype PDF File size 0.87 MB Source: rwjms.rutgers.edu
PCM Guidebook for History Taking and Physical Exams PATIENT CENTERED MEDICINE OFFICE OF EDUCATION Copyright Rutgers Robert Wood Johnson Medical School PCM 2009-2017 This guide is designed to provide the following information: SECTION PAGES This book was developed by the multidisciplinary steering committee for Patient Centered Medicine. It is meant to be a guide for your patient encounter. For further detail, please see your textbook and speak with your clinical supervisor. How to elicit a Patient Centered History Pages 3 -7 and History of the Present Illness • The Past Medical History Page 8 • The Family History Page 9 • The Social History Pages 10-20 • How to elicit a Review of Systems Pages 21-30 How to perform a Physical Exam Pages 31–48 The Pediatric Patient Pages 49–59 The Write-up Pages 60–67 Appendices 1-9 and Notes Pages 68-79 2 HOW TO ELICIT A PATIENT CENTERED HISTORY AND HISTORY OF THE PRESENT ILLNESS Opening and facilitating the interview - Key actions 1. Wash your hands before and after encounter 2. Introduce yourself (state your first and last name and that you are a medical student) to patient and anyone else who is with the patient. Include who you are working with (attending or resident name). 3. Address the patient appropriately (use patient’s last name or preferred name and personal pronoun) Identify patient with first and last name and ask how they would like to be addressed. 4. Explain the purpose of the interview 5. Offer a social comment or ask a non-clinical question to put patient at ease 6. Assure privacy and pull curtains as appropriate 7. Assure comfort 8. Sit down in a chair if feasible 9. Allow the patient to express themself 10. Ask if patient has any questions and respond to questions appropriately 11. Adapt your language, pace, and posture in response to the patient 12. Present yourself professionally both verbally and nonverbally 13. Demonstrate empathy, concern, and compassion 3 Closing the Interview – Key actions 1. Consider summarizing key history and physical exam findings 2. Provide an explanation of what you think is going on – working diagnosis, other possible diagnoses 3. Provide specific next steps 4. Ask patient/family if they have questions 5. Ensure understanding – “teach-back” 6. Thank patient. 4
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