Proficiency/Skill: Patient Questioning, Record Keeping & Documentation

A) In the United States, a typical doctor’s visit lasts only 15 to 20 minutes on average. Because
time is limited with each patient, it is important that a doctor is efficient and thoughtful in
deciding what questions to ask. Generate a list of at least 6 questions that will help you, the
primary care physician, get to know your patient, assemble a thorough medical history, and
assess whether the patient has any concerns about their health.
1. What brings you in today?
2. Do you have any ongoing medical conditions or past surgeries I should know about?
3. Do you have any allergies, including to medications, foods, or environmental triggers?
4. What is your lifestyle like in terms of diet, exercise, sleep, and stress levels?
5. Is there anything specific you’re worried about regarding your health?
6. Are you currently taking any medications, supplements, or over-the-counter remedies?

B) Read through the patient information in the medical history cards located in the chart below.
Skill/Task: You are a primary care physician within a well-established private practice. Below
are medical history cards of three new patients that you have no previous knowledge about.
Develop questions that you would you ask each of the patients to get the patient to reveal the key
targets from their respective medical history card. Be sure to consider the patient's age.in your
question development.

1. What brings you in today?

2. Where do you live, and are there any environmental factors, like nearby factories or
allergens, that might affect your health?
3. Do you have a family history of health issues, such as heart disease or cancer?
4. Have you ever had any major surgeries or hospitalizations in the past?
5. Have you traveled recently? If so, where did you go, and did you experience any unusual
symptoms during or after your trip?

1. Can you tell me about any past injuries or surgeries, such as accidents earlier in life, and
how they have affected you?
2. What does your current family life look like? Are you living with anyone, and how is
your support system?
3. What type of environment do you live in, and what activities do you enjoy doing in your
free time?
4. Can you share more about your career? Did your work involve any physical demands or
exposure to health risks?
5. Are you currently taking any medications? If so, what are they for, and how well are they
managing your conditions?
 1. Can you tell me more about the sharp pains in your belly? When did they start, and have
you noticed any specific foods or situations that make them worse?
2. Where do you live, and how do you typically get to school or other places? Do you notice
any factors in your environment that might affect your health?
3. What do you like to do in your free time? Are there any recent activities or hobbies
you’ve participated in that stand out?
4. Have you had any major dental or medical procedures recently? How have you been
feeling since then?
5. What does your typical diet look like? Are there any particular foods or drinks you enjoy
regularly?

C) Read through the medical interview transcript attached here: Patient Interview Script.pdf.
Complete a medical history report for the patient based upon the information revealed from the
medical interview.

Patient Reminders:
- EVENT COORDINATOR– VERY STRESSFUL ENVIRONMENT
- MOSTLY DRINKS CAFFEINE
- NO ALCOHOL OR SMOKING
- MARRIED WITH NO CHILDREN
Medications:
- IBUPROFEN
- MULTIVITAMIN
Appointment Notes:
- HEADACHE STARTED THREE DAYS AGO
- BRIGHT LIGHT MAKES PAIN WORSE
- NO CHANGES IN DIET OR LIFESTYLE
- TOOK IBUPROFEN, DID NOT HELP
- PAIN: 7/10– AREAS: TEMPLES
- NAUSEA
- VOMITING
- WAS IN MINNESOTA LAST WEEK– IN THE VICINITY OF A SICK CHILD
Family History:
- MOTHER USED TO GET MIGRAINES
- DAD HAS HIGH BLOOD PRESSURE AND HIGH CHOLESTEROL
- GRANDFATHER HAS LUNG CANCER
Health Conditions:
- ELEVATED BLOOD PRESSURE LAST VISIT/ALTERED DIET
- APPENDECTOMY
D) Reflect using the guiding questions. Why is the skill important? Do you intend to implement
the skill in your future? How so? Do you feel proficient in the skill/ competent in performing the
skill in school and/or in the workforce? Explain. Patient questioning, record keeping, and
documentation are essential components of medical practice because they ensure effective
communication between healthcare providers, promote accurate diagnosis and treatment, and
safeguard patient safety. Thorough questioning helps uncover key aspects of a patient’s medical
history, which can guide clinical decisions. Proper documentation creates a record that can be
referred to in future visits, helping to track progress and identify any patterns in health changes.
Record-keeping also serves as a legal safeguard, ensuring that patient information is accurately
recorded and can be accessed by other healthcare professionals when needed. Yes, I plan to
implement these skills in my future because I plan to be a nurse. Effective patient questioning,
record keeping, and documentation are crucial in nursing to ensure proper care and
communication. I feel proficient in these skills because I have versatile experience in
communicating with people of different ages and conditions. This has helped me understand the
importance of active listening and accurate documentation, which are essential for providing
quality care and working collaboratively with other healthcare professionals.