History And Physical Template Medical: Fill & Download for Free

Thanks for A2A!!I would like to take this opportunity to underscore the importance of communication skills in healthcare which all begins with a good history taking and physical exam which translates to an effective case presentation.Why bother with history and physical exam at all?I do not disagree that medical imaging has evolved a lot over the last few decades, however a good case history helps you localise the disease pattern to a particular system thereby giving you a clue as to where to look for.Trust me it is not easy in a lot of cases. Better said than done.You can't just roll every patient that walks into your OPD to a CT scanner and expose him / her to a lifetime worth of radiation in a single day !!With escalating health care budgets, this excess reliance on imaging to guide patient management is highly unsustainable.Some initial considerations :Take time to talk to the patient and actually understand what he is in for !! Try to get to the ward / hospital unit by 8:30 or so in the morning so that you will be ready with a complete case for presentation by 10 which in turn can translate to 2 good hours of discussion with the consultant.It scares me to see medical students coming in casually at 10 and joining the discussion right away with no clue as to who the patient even is.That being said, it is totally fine if you wish to bunk the classes in afternoon / sleep through them as I particularly found them of no much use. So work hard in wards and rest in the class.Try building a rapport with the patient by looking at things from his / her perspective. Help if possible by getting an investigation done earlier or by explaining the condition for which he / she is being treated. Once you earn that trust, you can better understand what’s actually going on with the patient.Involve the patient family in your discussion with the patient and give them time to speak, rather than blabbering your bookish knowledge in front of them.Always respect the privacy of the patient while doing a clinical examination. Use appropriate screening when necessary. A comfortable patient yields good clinical signs.Try to have a plan about what you want to examine tomorrow on the medical / surgical ward so that you are better prepared to elicit a good history.It is a good idea to prepare a template / pro forma before hand of what to ask and what to examine during patient encounter. Saves a lot of time.How to polish your technique ?Practise presenting the whole case in front of a mirror. Definitely helps.Practise with a study partner to brush up your clinical exam skills while another candidate assesses your moves and comments on what needs to be improved at the end of the session.Very effective technique to practise communication skills involving patients and physical examination skills, many underestimate this.Try explaining the case / presenting to a friend or take turns in presenting it to a small group, you will realise what your road - blocks are.Most students including me initially have a hard time speaking / conversing in English language and I don't deny it is a drawback.However, take time and put effort to form sentences and converse in English with a friend. That really breaks the ice during case presentation.Feynman’s technique :Throughout my residency in general surgery, I never presented a single case to my consultants, however I did pretty well during my assessment in both MRCS and MS General Surgery university exams.This is attributed to a large extent to Feynman’s technique.I made sure that I explained all the cases on the surgical ward to medical students posted in my unit and in the process learnt how and what to present.It basically means learning through teaching.Source : Filling the Knowledge Gap in the Produced Water Industry - The Feynman TechniqueMe with some of my junior colleagues. Had a great time interacting with them in Osmania General.And a few more ….How does all of this help in routine clinical practice ??Poor Communication Leading Cause of Medical Negligence - Zevan Davidson Roman, LLCHow communication problems put patients, hospitals in jeopardy This study analysed 23,000 cases.Communication gaffes: a root cause of malpractice claims This one is straight from NIH.To Be Sued Less, Doctors Should Consider Talking to Patients More NewYork TimesRole of communication in medical malpractice Published research in Wiley.Now if it is from a single source it may be wrong, but the evidence keeps piling in favour of poor communication.It’s not leaving behind an instrument or lack of performing a investigation but poor communication meaning poor history taking, physical exam and not spending appropriate time to explain stuff to the patient is the single largest cause of lawsuits / medical negligence.We could play our part to bridge the gap with good clinical skills and bedside manners.So, learn these skills not to pass the university exams or to join PG but to better treat your patients, after all that’s what we are strive to do at the end of the day as doctors.Good luck to us all!

So many things are getting lost.But, I would have to say, right now, that the skill I grieve for most is the art of storytelling.Many people don't realize this, but a big part of a doctor’s onus is to convey the essence of the patient, their history, the story of their illness, including what they think is the problem, and what they have done to treat it.These narratives are called ‘History and Physicals’ or H&Ps. They are the backbone of the patient’s care. Every single physician, nurse, and other practitioner would consult this document to acquaint themselves with the patient’s history and baseline physical exam. They would run something like:“Mrs. Smith is 45 year old married woman who presents today with a complaint of a headache for three days. She denies any nausea, vomiting or trauma to the head. She states she has a history of migraine headaches, which started in her early teens.”It would then proceed to address the patient’s past medical history, family history and then the physical exam. They would always be set up in SOAP format, and would end with the assessment and plan.These would be transcribed from a doctor who would dictate this information typically, right after seeing the patient. The transcription would generally take less than an hour, and voila, it appears in their medical record.Now, thanks to the bumbled efforts with EHR and the oncoming generation’s dislike of speaking into a phone, the records look like:Male ( ) Female (X ) presents with chest pain ( ) nausea ( )vomiting ( ) headache ( X). And so on.Doctors are now set up with their own templates in which they click boxes. Not just H&Ps, but operative notes and progress notes. They also pull in every lab, vital sign, radiology result, medication orders etc. from the last 36 hours so they have become very much like spam notes.Reading them is the visual equivalent of army crawling through barbed wire.An attending that I work with and I recently had this discussion about these templates and he had this to say:“The residents don't even use the phone to dictate anymore. I suggested to a first year that she just dictate the H&P while they were getting a patient ready for surgery. She was flabbergasted, she had never dictated and said that if she couldn't just text something it threw her off.”Electronic health records-welcome to the new boss.

I will try to lend some perspective from my experience.I am routinely, consistently late seeing patients at their appointment time. My typical statement to them, after introductions, is, “Sorry to keep you waiting.”I perform weight loss surgery. Each new patient is scheduled for a 30 minute period, although there are often two patients scheduled to be seen in that 30 minute block. This leaves me 15 minutes per patient. The first patients of the day, provided they are on time, see me, a nurse practitioner, and a dietitian in that 30 minutes, so if there are two patients neither of them are waiting to see a provider.When a patient is scheduled for a new patient appointment, they are asked to review a webinar available and easily found on our website. The webinar goes over the operations, how they work, the different options and why the surgeon may recommend one over the other, the surgical and long term risks, the preoperative preparation, the anticipated length of stay in the hospital, the expected recovery period and time off work, the medications they may be on, the diet, and the expected outcomes in terms of weight loss and impact on the patient’s health.Only about half of the patients watch this webinar.In that 15 minutes I am allotted to see the patient, I am required to:1. Take a comprehensive history and physical;2. Answer any questions the patient has about the operations;3. Discuss my recommendations for type of operation;4. If they have not watched the webinar, try to cover much of the same material that is in it so the patient has some clue about what is going to happen.That is a lot of ground to cover. If the patient has a complex medical or surgical history (as many of my patients do), the history taking and counseling can take even longer. So I routinely go past 15 minutes per patient.If patients are late for their appointment, which often happens, I still see them. If they are over 20 minutes late, I will offer to reschedule them or see them at the end of the office session (end of the morning or end of the afternoon), even if that means I use my lunch hour to see the patients.The end result of all of this is I am routinely running late. I cannot change the schedule template because it is set by my institution (which employs me). For the most part, the schedule works and wait times are not excessive. I also give as much time to every patient as they need, which means my patients are informed, feel cared for as people, and do not feel rushed. Every patient gets me for as long as they need, within reason. If they are so complex that I do not think I can cover everything in one session, I ask them for a follow up visit, which we now often do by telemedicine so the patient does not have to come to the office.Patients should look at a doctor with a full office and delays as a physician who is in high demand because she is competent, caring, and patient. We try to do the best we can in an imperfect system. I see just as many complaints from patients about their doctor saying, “My doctor was rushed and did not give me the time I needed.” We try to balance punctuality with comprehensive, caring treatment.Patient care is not an assembly line.