History taking, physical examination, communication, and interpersonal behavior are all skills that can be improved by training, practice, and critique.
Greet the patient and state your name.
Elicit or confirm the patient’s name.
Never attempt to communicate with the patient other than as a physician to patient.
Feel free to take notes during the encounter. (Blank paper will be provided)
Concentrate on the case on which you are working.
Notify proctors or evaluators of any problems.
Begin with broad questions and then focus your inquiries.
Don’t rush the patient’s answers.
Don’t cut the patient’s answers off with another question.
Repeat your questions in different terms if necessary.
Ask follow-up questions.
Wash your hands between patients, preferable before touching the patient or beginning the physical examination.
Tell the patient when you are going to begin the physical exam.
Describe the maneuvers either before or as you do them.
Always use patient gowns and drapes appropriately to maintain patient modesty and comfort.
Maintain the patient’s modesty, but never examine through the gown.
Do a focused examination based on the patient’s complaint, symptom, and history.
Look for physical findings.
Note the time warning for 2 minutes remaining in the encounter.
Close the encounter when the “End of Encounter” signal is given.
When appropriate, tell the patient your initial impressions and your plan for the diagnostic work-up.
When appropriate, ask for, and answer any additional questions.
Do not perform rectal, pelvic/genital, or female breast exams.
Make eye contact.
Ask clear questions.
If you use medical terms, explain yourself.
Be direct and honest, but also be sensitive.
If you don’t know the answer to an SP’s question, say so.
Acknowledge the patient’s concerns or worries.