CHECK LIST FLOW SHEET – FOR test day (MINE)

1. KNOCK KNOCK – enter smiling! = point

2. Mz/Mr (last name) Mr. Jones? – Hi, I am Dr. Le….I am the physician on call/duty today. Nice to
meet you – SMILE!! = point
a. Wash hands – I’ll be taking care of you today,
i. First I’ll ask you questions,
ii. then I’ll do a quick physical exam,
iii. then I’ll give you my impressions, - WILL THAT OKAY WITH YOU? (- asked
permission)

SIT DOWN on stool as say:

 Do you mind if I sit down and TAKE A FEW NOTES while we talk?
 May I have a seat & take some notes?
o I AM PERIODICALLY GOING TO BE TAKING NOTES, BUT THAT’S JUST
SO THAT I DON'T MISS ANY IMPORTANT INFO YOU GIVE ME.
PLEASE BE ASSURED- YOU HAVE MY UNDIVIDED ATTENTION"

3. Please tell me, how can I help you today/What brings you in today?
a. Pt: I have blood in my urine

4. I AM SO SORRY TO HEAR THAT (Genuine concern empathy – support emotions = point)

5. DRAPE & say CAN I MAKE YOU MORE COMFORTABLE?

a. Are you COMFORTABLE?
b. Are you comfortable sitting up or lying down?) = POINT

6. CAN YOU TELL ME more about (your/this….. (chief complaint)….

 when u decide the SP has said something u need to write ---

o tell him: "I AM PERIODICALLY GOING TO BE TAKING NOTES, BUT THAT IS
JUST SO THAT I DON'T MISS ANY IMPORTANT INFO YOU GIVE ME.
PLEASE BE ASSURED THAT U HAVE MY UNDIVIDED ATTENTION"

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

EMPATHY & Get back to focused history -

 I understand this can be frustrating to you, but I want you know this will be a team effort
 Patient tells lengthy story irrelevant to CC, INTERRUPT POLITELY:
o “Excuse me, Mr. Johnson. I understand how important those issues are for you, but I’d
like to ask you some additional questions about your current problem.”

o “So as I understand it, your abdominal pains are infrequent, last a short time, and are
always in the middle of your belly. Now tell me about . . .”). – Summary, redirect convo.
Move to next step

o You look sad; do you know the reason?” or

o “You look concerned; is there anything that is making you worry?.
  I UNDERSTAND THIS CAN BE FRUSTRATING TO YOU, BUT I WANT YOU KNOW
THIS WILL BE A TEAM EFFORT

TRANSITION PHRASE: HPI to PMH

 “I need to ask you some questions about your health in the past,
o PAM HITS FOSS – SODA TED

At end, before Physical Exam:

 “Is there anything you would like to add that I might have missed? "
 “Is there anything else you forgot to tell me about?”
 DO you have anything you would like to add?

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

PHYSICAL EXAM SECTION - MAY I BEGIN the PHYSICAL EXAM?

CHECK LIST – PHYSICAL EXAM

1. MAY I BEGIN the PHYSICAL EXAM?
2. WASH Hands – a little hand sanitizer “have you gone holiday shopping?”
3. DRAPE PATIENT
4. INFORM PT OF STEPS
5. WARM STETHASCOPE + USE DISPOSABLE TOOLS
6. EXAM Under the gown
7. Don’t repeat painful maneuvers
8. Don’t do Breast/Pelvic/Rectal/Genital exams
9. FOCUSED EXAM related systems

AFTER PHYSICAL EXAM:

 Thank you for letting me examine you and answering all of my
questions. Before I tell you my IMPRESSION, I would like to ask you a
few more questions….
 What do you think is causing this?
o How is this affecting Your life? ((Impact on pt life))

PHYSICAL EXAM: DO NOT FORGET – easy mistakes

1. Don’t spend too long on History – If HEAR 5 mins (May I begin the physical exam?)
2. Do brief exam focused & Conclude/counsel
3. PULL FOOTREST out - when check ABDOMEN!!
4. NEURO exam when (MSK, NEURO/stroke/memory/Thyroid)
5. HTN – check OPHTHALMOSCOPE (no AV nicking?, no cotton whool spots?)