Communication steps during procedures:

For any invasive examination or procedure (including intimate ones), there are several stages or steps
in communication necessary to adequately inform the patient. During any particular encounter, these
steps may not always occur in the order presented below, but can serve as a checklist to ensure that
you have covered the necessary information. Remember that while each procedure may become
routine for you, it is never routine for the patient, and they are often apprehensive about what to expect.

Step 1: Why do you need the procedure? (related to Step 6)

 Current assessment of problem before the procedure, including indication(s)
 Is the procedure being done for diagnostic or therapeutic purpose, or both?
o Will it assist with determining diagnosis – what are possible diagnoses?
o Will it assess the severity and extent of the problem?
o How will this procedure help the problem?
 Which other tests may be done during the procedure?
 Allow the patient to ask questions

Step 2: What does the procedure involve? (related to Step 5)

 Enquire about prior experience
 General summary description of what procedure involves – focus on patient’s experience
 Realistic estimate of discomfort
 Realistic estimate of time taken
 Allow the patient to ask questions

Step 3: What are the possible complications/ risks? (know for exams!!)
 Common risks of bleeding, infection, anaesthesia (if used), and allergic reactions for any
invasive procedure
 Particular risks of THIS procedure (ie. what else can go wrong, what other structures might
be damaged?)
 Quantify each risk as high, moderate or low – risk may change for a particular patient context
 How will you minimize the risks?
 Risks of not doing procedure, or of procedure failure
 Consider contra-indications to the procedure prior to discussion
 Allow the patient to ask questions

Step 4: Obtain consent

 Address patient concerns and questions
 Verbal and/or written consent from patient or guardian

Step 5: Language during procedure (related to Step 2)

 Before, during, and after the procedure itself
 Patient positioning and setting up
 Step-by-step description of what you are doing (and normal findings)as appropriate – focus
on the patient experience
 Warning of discomfort
 Patient instructions should be clear, simple and easy to understand
 Check patient comfort throughout

Step 6: Results and further action (related to Step 1)

 What did you find?
 Have you confirmed or excluded a diagnosis/diagnoses considered above?
 What other tests did you obtain during the procedure?
 Are any further procedures or testing needed?
 Follow-up needed post-procedure?
 Allow the patient to ask questions
 Relates to ‘Giving Information to Patients’ SASU session

Practice going through these steps for each procedure you may be asked to perform or observe. You
will find that you will develop your own style when communicating with patients about procedures, and
may eventually develop your own ‘script’ for those procedures you do often.

Student Academic Support Unit (SASU)

Monash University Faculty of Medicine, Nursing and Health Sciences
Erica Schmidt, MD 2009 updated Jan 2016
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