Health Blog

Tips | Recommendations | Reviews

What Is An Encounter In Healthcare?

What Is An Encounter In Healthcare
This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times). See the Directory of published versions Detailed Descriptions for the elements in the Encounter resource.

Encounter Element Id Encounter Definition An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. Encounter is primarily used to record information about the actual activities that occurred, where Appointment is used to record planned activities. Short Display An interaction during which services are provided to the patient Cardinality 0.* Type DomainResource Alternate Names Visit Summary false Encounter.identifier Element Id Encounter.identifier Definition Identifier(s) by which this encounter is known. Short Display Identifier(s) by which this encounter is known Note This is a business identifier, not a resource identifier (see discussion ) Cardinality 0.* Type Identifier Summary true Encounter.status Element Id Encounter.status Definition The current state of the encounter (not the state of the patient within the encounter – that is subjectState). Short Display planned | in-progress | on-hold | discharged | completed | cancelled | discontinued | entered-in-error | unknown Cardinality 1.1 Terminology Binding Encounter Status ( Required ) Type code Is Modifier true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) Summary true Comments Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes). Encounter.class Element Id Encounter.class Definition Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations. Short Display Classification of patient encounter context – e.g. Inpatient, outpatient Cardinality 0.* Terminology Binding Encounter class ( Preferred ) Type CodeableConcept Summary true Encounter.priority Element Id Encounter.priority Definition Indicates the urgency of the encounter. Short Display Indicates the urgency of the encounter Cardinality 0.1 Terminology Binding ActPriority ( Example ) Type CodeableConcept Summary false Encounter.type Element Id Encounter.type Definition Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). Short Display Specific type of encounter (e.g. e-mail consultation, surgical day-care,,) Cardinality 0.* Terminology Binding Encounter Type ( Example ) Type CodeableConcept Summary true Comments Since there are many ways to further classify encounters, this element is 0.*. Encounter.serviceType Element Id Encounter.serviceType Definition Broad categorization of the service that is to be provided (e.g. cardiology). Short Display Specific type of service Cardinality 0.* Terminology Binding Service Type ( Example ) Type CodeableReference ( HealthcareService ) Summary true Encounter.subject Element Id Encounter.subject Definition The patient or group related to this encounter. In some use-cases the patient MAY not be present, such as a case meeting about a patient between several practitioners or a careteam. Short Display The patient or group related to this encounter Cardinality 0.1 Type Reference ( Patient | Group ) Alternate Names patient Summary true Comments While the encounter is always about the patient, the patient might not actually be known in all contexts of use, and there may be a group of patients that could be anonymous (such as in a group therapy for Alcoholics Anonymous – where the recording of the encounter could be used for billing on the number of people/staff and not important to the context of the specific patients) or alternately in veterinary care a herd of sheep receiving treatment (where the animals are not individually tracked). Encounter.subjectStatus Element Id Encounter.subjectStatus Definition The subjectStatus value can be used to track the patient’s status within the encounter. It details whether the patient has arrived or departed, has been triaged or is currently in a waiting status. Short Display The current status of the subject in relation to the Encounter Cardinality 0.1 Terminology Binding Encounter Subject Status ( Example ) Type CodeableConcept Summary false Comments Different use-cases are likely to have different permitted transitions between states, such as an Emergency department could use arrived when the patient first presents, then triaged once has been assessed by a nurse, then receiving-care once treatment begins, however other sectors may use a different set of these values, or their own custom set in place of this example valueset provided. Encounter.episodeOfCare Element Id Encounter.episodeOfCare Definition Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years). Short Display Episode(s) of care that this encounter should be recorded against Cardinality 0.* Type Reference ( EpisodeOfCare ) Summary true Encounter.basedOn Element Id Encounter.basedOn Definition The request this encounter satisfies (e.g. incoming referral or procedure request). Short Display The request that initiated this encounter Cardinality 0.* Type Reference ( CarePlan | DeviceRequest | MedicationRequest | ServiceRequest ) Alternate Names incomingReferral Summary false Encounter.careTeam Element Id Encounter.careTeam Definition The group(s) of individuals, organizations that are allocated to participate in this encounter. The participants backbone will record the actuals of when these individuals participated during the encounter. Short Display The group(s) that are allocated to participate in this encounter Cardinality 0.* Type Reference ( CareTeam ) Summary false Encounter.partOf Element Id Encounter.partOf Definition Another Encounter of which this encounter is a part of (administratively or in time). Short Display Another Encounter this encounter is part of Cardinality 0.1 Type Reference ( Encounter ) Hierarchy This reference is part of a strict Hierarchy Summary false Comments This is also used for associating a child’s encounter back to the mother’s encounter. Refer to the Notes section in the Patient resource for further details. Encounter.serviceProvider Element Id Encounter.serviceProvider Definition The organization that is primarily responsible for this Encounter’s services. This MAY be the same as the organization on the Patient record, however it could be different, such as if the actor performing the services was from an external organization (which may be billed seperately) for an external consultation. Refer to the colonoscopy example on the Encounter examples tab. Short Display The organization (facility) responsible for this encounter Cardinality 0.1 Type Reference ( Organization ) Summary false Encounter.participant Element Id Encounter.participant Definition The list of people responsible for providing the service. Short Display List of participants involved in the encounter Cardinality 0.* Summary true Comments Any Patient or Group present in the participation.actor must also be the subject, though the subject may be absent from the participation.actor for cases where the patient (or group) is not present, such as during a case review conference. Invariants
Defined on this element
enc-1 Rule A type must be provided when no explicit actor is specified actor.exists() or type.exists()
enc-2 Rule A type cannot be provided for a patient or group participant actor.exists(resolve() is Patient or resolve() is Group) implies type.exists().not()

/td> Encounter.participant.type Element Id Encounter.participant.type Definition Role of participant in encounter. Short Display Role of participant in encounter Cardinality 0.* Terminology Binding Participant Type ( Extensible ) Type CodeableConcept Summary true Comments The participant type indicates how an individual actor participates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc. Invariants

Affect this element
enc-1 Rule A type must be provided when no explicit actor is specified actor.exists() or type.exists()
enc-2 Rule A type cannot be provided for a patient or group participant actor.exists(resolve() is Patient or resolve() is Group) implies type.exists().not()

/td> Encounter.participant.period Element Id Encounter.participant.period Definition The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter’s period. Short Display Period of time during the encounter that the participant participated Cardinality 0.1 Type Period Summary false Encounter.participant.actor Element Id Encounter.participant.actor Definition Person involved in the encounter, the patient/group is also included here to indicate that the patient was actually participating in the encounter. Not including the patient here covers use cases such as a case meeting between practitioners about a patient – non contact times. Short Display The individual, device, or service participating in the encounter Cardinality 0.1 Type Reference ( Patient | Group | RelatedPerson | Practitioner | PractitionerRole | Device | HealthcareService ) Summary true Comments For planning purposes, Appointments may include a CareTeam participant to indicate that one specific person from the CareTeam will be assigned, but that assignment might not happen until the Encounter begins. Hence CareTeam is not included in Encounter.participant, as the specific individual should be assigned and represented as a Practitioner or other person resource. Similarly, Location can be included in Appointment.participant to assist with planning. However, the patient location is tracked on the Encounter in the Encounter.location property to allow for additional metadata and history to be recorded. The role of the participant can be used to declare what the actor will be doing in the scope of this encounter participation. If the individual is not specified during planning, then it is expected that the individual will be filled in at a later stage prior to the encounter commencing. Invariants

Affect this element
enc-1 Rule A type must be provided when no explicit actor is specified actor.exists() or type.exists()
enc-2 Rule A type cannot be provided for a patient or group participant actor.exists(resolve() is Patient or resolve() is Group) implies type.exists().not()

/td> Encounter.appointment Element Id Encounter.appointment Definition The appointment that scheduled this encounter. Short Display The appointment that scheduled this encounter Cardinality 0.* Type Reference ( Appointment ) Summary true Encounter.virtualService Element Id Encounter.virtualService Definition Connection details of a virtual service (e.g. conference call). Short Display Connection details of a virtual service (e.g. conference call) Cardinality 0.* Type VirtualServiceDetail Summary false Comments There are two types of virtual meetings that often exist:

a persistent, virtual meeting room that can only be used for a single purpose at a time, and a dynamic virtual meeting room that is generated on demand for a specific purpose.

Implementers may consider using Location.virtualService for persistent meeting rooms. If each participant would have a different meeting link, an extension using the VirtualServiceContactDetail can be applied to the Encounter.participant BackboneElement. Encounter.actualPeriod Element Id Encounter.actualPeriod Definition The actual start and end time of the encounter. Short Display The actual start and end time of the encounter Cardinality 0.1 Type Period Summary false Comments If not (yet) known, the end of the Period may be omitted. Encounter.plannedStartDate Element Id Encounter.plannedStartDate Definition The planned start date/time (or admission date) of the encounter. Short Display The planned start date/time (or admission date) of the encounter Cardinality 0.1 Type dateTime Summary false Encounter.plannedEndDate Element Id Encounter.plannedEndDate Definition The planned end date/time (or discharge date) of the encounter. Short Display The planned end date/time (or discharge date) of the encounter Cardinality 0.1 Type dateTime Summary false Encounter.length Element Id Encounter.length Definition Actual quantity of time the encounter lasted. This excludes the time during leaves of absence. When missing it is the time in between the start and end values. Short Display Actual quantity of time the encounter lasted (less time absent) Cardinality 0.1 Type Duration Summary false Comments If the precision on these values is low (e.g. to the day only) then this may be considered was an all day (or multi-day) encounter, unless the duration is included, where that amount of time occurred sometime during the interval. May differ from the time in Encounter.period due to leave of absence(s). Encounter.reason Element Id Encounter.reason Definition The list of medical reasons that are expected to be addressed during the episode of care. Short Display The list of medical reasons that are expected to be addressed during the episode of care Cardinality 0.* Summary true Comments The reason communicates what medical problem the patient has that should be addressed during the episode of care. This reason could be patient reported complaint, a clinical indication that was determined in a previous encounter or episode of care, or some planned care such as an immunization recommendation. In the case where you have a primary reason, but are expecting to also address other problems, you can list the primary reason with a use code of ‘Chief Complaint’, while the other problems being addressed would have a use code of ‘Reason for Visit’. Examples:

pregnancy would use HealthcareService or a coding as the reason patient home monitoring could use Condition as the reason

Encounter.reason.use Element Id Encounter.reason.use Definition What the reason value should be used as e.g. Chief Complaint, Health Concern, Health Maintenance (including screening). Short Display What the reason value should be used for/as Cardinality 0.* Terminology Binding Encounter Reason Use ( Example ) Type CodeableConcept Summary true Encounter.reason.value Element Id Encounter.reason.value Definition Reason the encounter takes place, expressed as a code or a reference to another resource. For admissions, this can be used for a coded admission diagnosis. Short Display Reason the encounter takes place (core or reference) Cardinality 0.* Terminology Binding Encounter Reason Codes ( Preferred ) Type CodeableReference ( Condition | DiagnosticReport | Observation | ImmunizationRecommendation | Procedure ) Alternate Names Indication; Admission diagnosis Summary true Encounter.diagnosis Element Id Encounter.diagnosis Definition The list of diagnosis relevant to this encounter. Short Display The list of diagnosis relevant to this encounter Cardinality 0.* Summary true Comments Also note that for the purpose of billing, the diagnoses are recorded in the account where they can be ranked appropriately for how the invoicing/claiming documentation needs to be prepared. Encounter.diagnosis.condition Element Id Encounter.diagnosis.condition Definition The coded diagnosis or a reference to a Condition (with other resources referenced in the evidence.detail), the use property will indicate the purpose of this specific diagnosis. Short Display The diagnosis relevant to the encounter Cardinality 0.* Terminology Binding Condition/Problem/Diagnosis Codes ( Example ) Type CodeableReference ( Condition ) Alternate Names Admission diagnosis; discharge diagnosis; indication Summary true Encounter.diagnosis.use Element Id Encounter.diagnosis.use Definition Role that this diagnosis has within the encounter (e.g. admission, billing, discharge ). Short Display Role that this diagnosis has within the encounter (e.g. admission, billing, discharge ) Cardinality 0.* Terminology Binding Encounter Diagnosis Use ( Preferred ) Type CodeableConcept Summary false Encounter.account Element Id Encounter.account Definition The set of accounts that may be used for billing for this Encounter. Short Display The set of accounts that may be used for billing for this Encounter Cardinality 0.* Type Reference ( Account ) Summary false Comments The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules. Encounter.dietPreference Element Id Encounter.dietPreference Definition Diet preferences reported by the patient. Short Display Diet preferences reported by the patient Cardinality 0.* Terminology Binding Diet ( Example ) Type CodeableConcept Requirements Used to track patient’s diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter. Summary false Comments For example, a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive). Encounter.specialArrangement Element Id Encounter.specialArrangement Definition Any special requests that have been made for this encounter, such as the provision of specific equipment or other things. Short Display Wheelchair, translator, stretcher, etc Cardinality 0.* Terminology Binding Special Arrangements ( Preferred ) Type CodeableConcept Summary false Encounter.specialCourtesy Element Id Encounter.specialCourtesy Definition Special courtesies that may be provided to the patient during the encounter (VIP, board member, professional courtesy). Short Display Special courtesies (VIP, board member) Cardinality 0.* Terminology Binding Special Courtesy ( Preferred ) Type CodeableConcept Summary false Comments Although the specialCourtesy property can contain values like VIP, the purpose of this field is intended to be used for flagging additional benefits that might occur for the patient during the encounter. It could include things like the patient is to have a private room, special room features, receive a friendly visit from hospital adminisitration, or should be briefed on treatment by senior staff during the stay. It is not specifically intended to be used for securing the specific record – that is the purpose of the security meta tag, and where appropriate, both fields could be used. Encounter.admission Element Id Encounter.admission Definition Details about the stay during which a healthcare service is provided. This does not describe the event of admitting the patient, but rather any information that is relevant from the time of admittance until the time of discharge. Short Display Details about the admission to a healthcare service Cardinality 0.1 Summary false Comments An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration recorded in the period of this encounter covers the entire scope of this admission record. Encounter.admission.preAdmissionIdentifier Element Id Encounter.admission.preAdmissionIdentifier Definition Pre-admission identifier. Short Display Pre-admission identifier Cardinality 0.1 Type Identifier Summary false Encounter.admission.origin Element Id Encounter.admission.origin Definition The location/organization from which the patient came before admission. Short Display The location/organization from which the patient came before admission Cardinality 0.1 Type Reference ( Location | Organization ) Summary false Encounter.admission.admitSource Element Id Encounter.admission.admitSource Definition From where patient was admitted (physician referral, transfer). Short Display From where patient was admitted (physician referral, transfer) Cardinality 0.1 Terminology Binding Admit Source ( Preferred ) Type CodeableConcept Summary false Encounter.admission.reAdmission Element Id Encounter.admission.reAdmission Definition Indicates that this encounter is directly related to a prior admission, often because the conditions addressed in the prior admission were not fully addressed. Short Display Indicates that the patient is being re-admitted Cardinality 0.1 Terminology Binding hl7VS-re-admissionIndicator ( Example ) Type CodeableConcept Summary false Encounter.admission.destination Element Id Encounter.admission.destination Definition Location/organization to which the patient is discharged. Short Display Location/organization to which the patient is discharged Cardinality 0.1 Type Reference ( Location | Organization ) Summary false Encounter.admission.dischargeDisposition Element Id Encounter.admission.dischargeDisposition Definition Category or kind of location after discharge. Short Display Category or kind of location after discharge Cardinality 0.1 Terminology Binding Discharge Disposition ( Example ) Type CodeableConcept Summary false Encounter.location Element Id Encounter.location Definition List of locations where the patient has been during this encounter. Short Display List of locations where the patient has been Cardinality 0.* Summary false Comments Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type “kind” such as “client’s home” and an encounter.class = “virtual”. Encounter.location.location Element Id Encounter.location.location Definition The location where the encounter takes place. Short Display Location the encounter takes place Cardinality 1.1 Type Reference ( Location ) Summary false Encounter.location.status Element Id Encounter.location.status Definition The status of the participants’ presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time. Short Display planned | active | reserved | completed Cardinality 0.1 Terminology Binding Encounter Location Status ( Required ) Type code Summary false Comments When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed. Encounter.location.form Element Id Encounter.location.form Definition This will be used to specify the required levels (bed/ward/room/etc.) desired to be recorded to simplify either messaging or query. Short Display The physical type of the location (usually the level in the location hierarchy – bed, room, ward, virtual etc.) Cardinality 0.1 Terminology Binding Location Form ( Example ) Type CodeableConcept Summary false Comments This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query. There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario. Encounter.location.period Element Id Encounter.location.period Definition Time period during which the patient was present at the location. Short Display Time period during which the patient was present at the location Cardinality 0.1 Type Period Summary false
See also:  What Is Pti In Healthcare?

What is an encounter for a patient?

An interaction between patient and healthcare providers to receive the care and treatments.

What is the difference between visits and encounters?

A visit is a collection of encounters that align with a clinical event (e.g., one or more encounters occurring during a patient’s visit to the clinic last Thursday) and can span days or weeks or more (e.g., an inpatient visit that started two weeks ago and comprises dozens of encounters containing daily notes & orders)

What is considered a clinical encounter?

Patient Encounter means any encounter where medical treatment and/or evaluation and management services are provided. For purposes of this rule, the entire course of an inpatient stay in a healthcare facility or treatment in an emergency department is considered a single patient encounter.

What is an encounter in epic?

Encounter= A clinical contact. For example, an office visit, an admission, or a telephone encounter. Even if more than one evaluation or procedure takes place at a visit, it is still usually considered one encounter.

What is an encounter?

: to come upon or experience especially unexpectedly. encounter difficulties. intransitive verb. : to meet especially by chance.

What is the concept of encounter?

Meaning of encounter in English. a meeting, especially one that happens by chance : I had an alarming encounter with a wild pig. This meeting will be the first encounter between the party leaders since the election.

Is there a difference between experience and encounter?

Experience or Encounter • Encounter Life Ministries I was sitting in an intercessory prayer group one night before the start of church, our first night in The Brown County Music Center, and one of my dear friends began to pray something like this, “Lord, turn off our evaluators tonight.” That simple, but profound beginning to a longer prayer, smacked me right in the face and got my attention.

It still has my attention. I had never heard anyone pray a prayer like that before. I had never thought of myself as having an evaluator until that night. But, let me tell you, I have one. I have an evaluator that goes into high gear when I’m in an environment with other people. I’m seeing every event through the eyes of every person, evaluating their experiences, which in turn causes me to over evaluate the experience as a whole.

I want people to be happy and enjoy themselves, and I’m good with changing an environment to make others have a great experience. Isn’t it human nature to evaluate an experience? Isn’t it normal to want to enjoy an experience? Aren’t we supposed to like our church experience? Aren’t we supposed to love the worship, the message, the people, the lights, the temperature, the seats? When we go to a concert or a sporting event or a movie, we leave and share our experience with others: I had the best seat in the house! The lighting was perfect! The sound couldn’t have been better! I give it a 10 out of a 10! We rate our experiences all the time.

We can even get on-line and rate a business experience, a restaurant experience, almost any experience can be publicly rated. When I think of an experience, I think of it as something I’m participating in, and I’m on the receiving end of it. It is happening to me. I am a spectator. I then evaluate and rate how I feel about what happened to me.

When I think of an encounter, I think about what I gave and what I received. I feel like I’m a participant in the event. When I think of an encounter, I think of an interaction, an exchange, a meeting. Dictionary.com gives the definition of encounter as, “to come upon or meet with, especially unexpectedly”.

It gives the definition of experience as, ” a particular instance of personally undergoing something.” Obviously, the words are similar in meaning, but they are also different. I also know my take on the words could very much be argued. But, stay with me on this. When I think about experiences and God, experiencing God, I think about something He is doing for me.

I see His goodness on display. I see Him in creation. I see Him in the way He supplies my needs. I feel like it is an emotional response to who God is and what He does for me. When I think about an encounter with God, I think about a meeting with God, a moment with Him.

  • I see it as an interaction with God.
  • I see it as more than an emotional response.
  • I see it as an intimate relationship with Him that is developed from moments with Him.
  • Back to our evaluators.
  • Merriam-Webster defines evaluate as, “means to determine the significance, worth, or condition of, usually by careful appraisal and study.

When you evaluate something, you’re making a judgment, one that most likely results from some degree of analysis.” We have to be so careful that we aren’t spending all of our time evaluating what’s happening around us that we miss the encounter God is wanting to have with us.

  • It’s so easy to slip into judgment and criticism which will steal our focus and attention.
  • Also, when I have had an encounter with God, I haven’t needed to “determine the significance, worth, or condition of” that encounter.
  • There were no words to describe it.
  • This prayer that night got me thinking about my own internal evaluator and how I evaluate each of my experiences.

This prayer also convicted me to the core. Am I coming to church for the experience, or am I coming to church for the encounter? Am I coming to church to create a pleasant experience for others, or do I want church to be a place where people have an encounter with God? Many churches call their services “Worship Experiences”.

  1. I don’t think there’s anything wrong with that title, but the Lord has really been changing my heart about this.
  2. He wants to have a “Worship Encounter” with us.
  3. He wants it to be a meeting with us that brings about new revelation, life change, healing, and wholeness.
  4. An Encounter with Jesus is often not what we ever expected.

How we rate an experience is typically based off of what we expected. We know how most experiences should go so we rate them to see how they meet our expectations. We know how church typically goes, so we often rate our experiences based off of our expectations.

  • God wants to encounter us, meet with us, in unexpected ways that change us forever.
  • We see many meetings with Jesus in the Bible that completely changed people forever.
  • And most of these encounters happened in very unexpected ways.
  • In Mark 7 we see Jesus heal the man who was deaf and could hardly talk.

One encounter with Jesus changed this man’s life and the lives of those around him. It was an intimate interaction with Jesus. Beginning in verse 31, it says, “Then Jesus left the vicinity of Tyre and went through Sidon, down to the Sea of Galilee and into the region of the Decapolis.

There some people brought to him a man who was deaf and could hardly talk, and they begged Jesus to place his hand on him. After he took him aside, away from the crowd, Jesus put his fingers into the man’s ears. Then he spit and touched the man’s tongue. He looked up to heaven and with a deep sigh said to him, “Ephphatha!” (which means “Be opened!”).

At this, the man’s ears were opened, his tongue was loosened and he began to speak plainly.” Wow! Can you imagine Jesus putting his fingers into your ears, spitting and touching your tongue? How do you evaluate that? You don’t. We all have areas of our lives that need healed.

  1. We have all suffered trauma because life is hard.
  2. John 16:33 says, “I have told you these things, so that in me you may have peace.
  3. In this world you will have trouble.
  4. But take heart! I have overcome the world.” We are desperate for these kinds of encounters with Jesus.
  5. An encounter with Jesus will change us.

It will heal us, and it will take deep-rooted beliefs that don’t line up with what God says about himself, about us, or about others and change them. An encounter will change those around us, too. An encounter will push us to action. In Acts 9, we see Saul’s transformation when he has an encounter with God.

He went from persecuting Christians to becoming a follower of Jesus. Beginning in verse one of chapter 9, it says, “Then Saul, still breathing threats and murder against the disciples of the Lord, went to the high priest and asked letters from him to the synagogues of Damascus, so that if he found any who were of the Way, whether men or women, he might bring them bound to Jerusalem.

As he journeyed he came near Damascus, and suddenly a light shone around him from heaven. Then he fell to the ground, and heard a voice saying to him, “Saul, Saul, why are you persecuting Me?” And he said, “Who are You, Lord?” Then the Lord said, “I am Jesus, whom you are persecuting.

It is hard for you to kick against the goads.” So he, trembling and astonished, said, “Lord, what do You want me to do?” Then the Lord said to him, “Arise and go into the city, and you will be told what you must do.”‘ Do we know people who are in need of a complete and total life change? Are we one of those people? We need these kinds of encounters with Jesus.

I have thought about the prayer, “Lord, turn off our evaluators tonight”, many times since that night, and God keeps revealing layers of truth to me. Is it wrong to evaluate? No. But, when we come to church, we need to come prepared to have an encounter with Jesus first, not just an experience.

  1. We need to pray and ask God to turn off our evaluators.
  2. Bring a jacket in case it’s too cold.
  3. Bring earplugs if the worship is too loud.
  4. Sing your own song if you don’t like one of the songs.
  5. But, come ready and open to have an encounter that will change you forever.
  6. May Encounter Life Ministries be a place where people encounter God in a way that brings healing and life change.

May we be a church that values encounter over experience. May we be a church that doesn’t hold God to our limited expectations, but rather, we allow Him to be the limitless God He is who desires to encounter us. Lord, turn our evaluators off and prepare us to encounter You in ways that we could never imagine.

What is an encounter vs episode of care?

In Healthcare IT, it’s important to understand the concept of episodes of care versus encounters. An encounter is a single event in which care is given. Individual office visits, ER visits, chemo appointments, and C-Sections are all encounters. An episode of care is a grouping of more than one encounter.

How patient outcomes are trending over time by episode How much is being spent per episode What external factors may be affecting patient’s health How to determine the average number of encounters per episode

Also, the US Healthcare system is moving away from a fee-for-service model where providers are paid only on the procedures and services delivered. This means that insurance companies are moving toward paying a flat fee for an episode of care. Electronic Health Records help providers to adapt to this model. Check out many more clinical and healthcare IT terms and definitions, Electronic prescribing of medications includes the technology and processes that handle medication orders as a replacement to paper prescriptions. To patients, e-prescribing is simply the electronic version of a,

What are the stages of patient encounter?

Providing Empathetic Two-Way Communication – Underlying patient-centered communication is empathetic and effective communication. Communication is a two-way process that involves both sending and receiving meaningful messages. If the receiver does not fully understand the message, effective communication has not occurred,

  1. As indicated in Figure 1-2, multiple personal and environmental factors influence the effectiveness of communication during clinical encounters.
  2. Attending to how each of these components may affect communication can make the difference between an effective and ineffective clinical encounter.
  3. Each party to a clinical encounter brings attitudes and values developed by prior experiences, cultural heritage, religious beliefs, level of education, and self-concept.
See also:  How Does Social Media Help Healthcare?

These personal factors affect the way a message is sent as well as how it is interpreted and received. Messages can be sent in a variety of ways and at times without awareness. Body movement, facial expression, touch, and eye movement are all types of nonverbal communication,

Combined with voice tone, nonverbal cues frequently say more than words. Because one of the purposes of the encounter is to establish a trusting relationship with the patient, the clinician must make a conscious effort to send signals of genuine concern, that is, to exhibit compassion and empathize with the patient’s circumstances.

Techniques useful for this purpose are facing the patient squarely, using appropriate eye contact, maintaining an open posture, using touch, and actively listening. It also may be helpful to act according to what you would expect from health care team members were you in the patient’s situation (the “golden rule” of bedside care).

  • One of the most common mistakes made by clinicians during patient encounters is failing to listen carefully to the patient.
  • Good listening skills require concentration on the task at hand.
  • Active listening also calls for replying to the patient’s comments and questions with appropriate responses.
  • Patients are quick to identify the clinician who is not listening and will often interpret this as a lack of empathy or concern.

If the patient says something you do not understand, it is best to ask the patient to clarify what was said rather than replying with the response you think is right. Asking for clarification tells the patient that you want to make sure you get it right.

Messages are also altered by feelings, language differences, listening habits, comfort with the situation, and preoccupation. Patients experiencing pain or difficulty breathing will have a hard time concentrating on what you are communicating until their comfort is restored. The temperature, lighting, noise, and privacy of the environment also may contribute to comfort.

Patients may communicate their discomfort nonverbally using cues such as sighing, restlessness, looking into space, and avoiding eye contact. Your use of communication techniques may differ according to the stage of interaction with a patient. Generally, a patient encounter begins with a chart review and then progresses through four additional stages: introductory, initial assessment, treatment and monitoring, and follow-up.

What are the steps of patient encounter?

Objectives: Learn how to address a patient in the Step 2 CS exam, developing a standard way of approaching patients efficiently by using a structured plan for the clinical history, physical exam, closure, and patient note. Use mnemonics to help to guide the examinee during the patient encounter and patient note. Step 2 CS Patient Encounter – Medical History to Closure (With Mnemonics) What Is An Encounter In Healthcare The patient encounter is composed of four major parts: the clinical history taking, physical exam, closure and patient note. It starts with the doorway information and finishes after one has finished typing the patient’s note. The actual encounter with the patient at the examination room determines the final scores of the CIS (Communication and Interpersonal Skills) and the SEP (Spoken English Proficiency) parts of the Step 2 Cs exam.

  • The physical examination and patient note are the two pillars of the ICE (Integrated Clinical Encounter) section.
  • Therefore, learning to approach the patient encounter in a standardized and efficient way is crucial for passing the exam.1.
  • ClINICAL HISTORY TAKING The best aid to use during the exam is the blue sheet of paper that the examination center will provide to the examinees.

Information about how to use this blue sheet as the best helper tool during the exam will be described continuously throughout this publication. Remember to make a transition statement when changing from one part to another. For example, when switching from the past medical history to the history of present illness, one might say, I would like to ask you about your current problem now, please? DOORWAY INFORMATION Before a case starts in the USMLE Step 2 CS exam, basic information about the patient will be described such as the name, age, gender, chief complaint, vital signs (if abnormal), indications for the case, etc.

  1. Making a mental differential diagnosis for the chief complaint that the patient holds. The more focused on the patient the better. For example, a patient with chest pain can have more probability of having a myocardial infarction if his age is >50 years old versus a younger patient.
  2. Writing down important information on the blue sheet that you may forget due to nervousness or lack of time to think during the encounter or patient note. What you can write involves mostly the differential diagnosis and mnemonics.

The time taken at the doorway should be the required for the applicant to be prepared to approach the case with confidence and clarity of mind. The standard time is 10-20 seconds (First Aid). However, in practice, it can take around 45 seconds to a minute to be ready to go in after writing down all one may need.

  • Knock the door before going into the room.
  • Verify the patient’s identity by asking, “Good morning, Mr. Jones?”
  • Keep eye contact as much as possible.
  • Introduce yourself, “Hi, I am Dr. X, nice to meet you.”
  • Shake hands firmly but gently. Do it with confidence and keep eye contact (handshake is important in the United States).
  • Drape the patient (most patients seen in the exam will be already draped).

THE CLINICAL HISTORY There are two ways of taking a clinical history (both of which generally start by asking the patient something like, what brings you in today?:

  1. Starting with the history of present illness (HPI): After asking what can I do for you today? and getting a reply such as, “I feel dizzy,” one can continue asking about the dizziness. Hence, finishing the history of present illness first and then moving on to the past medical history.
  2. Starting with the past medical history (PMH): After asking, how can I help you today? and getting a response like, “I have a headache,” one can transition into the past medical history saying, “I am sorry about that. Please, let me ask you about your background to better understand your current problem, all right? After finishing the PMH, one can continue with the HPI.

Which one is better is up to the examinee. There is an advantage of asking first about the past medical history, which is that you will be more oriented as to what is the most feasible cause of the chief complaint. A hypertensive and diabetic patient experiencing chest pain suggests more a cardiovascular cause comparing to a patient with chest pain and unknown history.

  • Past medical history: Ask about the past medical history, for example, “Have you ever been diagnosed with any medical condition?” Ask all about the disease like when it was diagnosed, for how long it has been present, treatments, and so on.
  • Hospitalizations: Have you ever been hospitalized before?
  • Past surgical history: Have you ever had any surgery in the past?
  • Medications: Are you taking any medications? Ask about prescribed and over the counter drugs.
  • Allergies: Do you have any allergy? Ask about allergies to medications, environmental elements, and the reaction originated from the exposure (eg. rash).
  • Social history: Occupation, diet, exercise. Also, ask about the important 3 bad habits: “SAI” smoking, alcohol and illicit drugs consumption. It is important to ask for when it started, how long it has been going on, the quantity used and the intention or attempts to quit the substance use. One can advise quickly about the advantage of quitting right away at this point, releasing some of the tasks needed to be done at the closure.
  • Sexual history: Ask about sexual behavior, partners, and safety taken.
  • OB/GYN: Ask about obstetric history (gestations, parturitions, abortions, cesareans, etc.) G1P1A0C0. Menstrual cycle, last menstrual period and anything else that you might consider important for the case.
  • Family history: Always ask about the history of the present problem. For example, if a patient is experiencing psychotic symptoms, asking about family history is important to identify a primary psychiatric disorder. Ask about direct family members (parents, brothers, and offspring).

The sexual and OB/GYN history are not always necessary to take. Thus it is at the examinee’s discretion if it is necessary to take them. In case of doubt, it is better to do it superficially unless otherwise required. It is NOT necessary to use mnemonics for the past medical history.

The reason is that the PMH is done almost in the same way for all cases and if practiced frequently enough, one will probably memorize it with ease. However, a mnemonic such as PAM HUGS FOSS can be used. HISTORY OF PRESENT ILLNESS (HPI) One can start with the chief complaint and then continue asking in detail what is relevant.

Do not forget to show compassion when a patient states experiencing a symptom such as pain. A simple phrase like, “I am sorry that you are experiencing this pain” or “That must be difficult for you” helps to build rapport with the patients. Using a mnemonic is recommended for the history of present illness.

  • A: Antiquity or age. Refers to the antiquity or age of the current problem. This letter has its own mnemonic P-OCDPSF
    • P: Prior events.
    • O: Onset. When did it start?
    • C: Constant or intermittent. Is the problem always present or does it comes and goes?
    • D: Duration. If constant ask when it started. If intermittent (episodic), ask when did the episodes started and how long they last.
    • P: Progression. Is the current problem worsening, the same, or getting better.
    • S: Setting in which it occurs. What were you doing when the pain started?
    • F: Frequency. How many times a day, week, or month does it occur?
  • L: Localization of the symptom such as pain.
  • I: It travels through the body or not? Radiation of the pain.
  • C: Characteristic of the pain. Is the pain sharp or dull?
  • I: Intensity. On a scale of 1 to 10, how would you rate your pain/symptom?
  • A: Aggravating and alleviating factors (two A’s). What makes it better? What makes it worse?
  • A: Associated symptoms with it.

REVIEW OF SYSTEMS (ROS): The review of systems should be focused on the current problem and special case needs. For example, a patient presenting with fatigue needs to be asked about the presence of constitutional symptoms. Therefore, learning a few short mnemonics for such cases may help: To screen for constitutional symptoms, infections, and other systemic disorders: WFA mnemonic

  • W: Weight loss or gain (unintentional).
  • F: Fever or chills.
  • A: Appetite changes such as anorexia.

To screen for thyroid disorders: C-C-H/S mnemonic

  • C: Constipation or diarrhea.
  • C: Cold or heat intolerance.
  • H/S: Hair and/or skin changes such as dry skin or alopecia.

To screen for neuropathic damage and neurologic disorders such as stroke T-N-W mnemonic

  • T: Tingling (sensory nerve disorder).
  • N: Numbness (sensory nerve disorder).
  • W: Weakness (motor abnormalities).

Tingling, numbness, and weakness should be asked together if possible. They screen for neuropathy and motor abnormalities. There are other very important mnemonics that are useful in specific cases. They are described in every chief complaint described in the Step 2 CS publications on this website.

  • Make a transition statement when planning to start the physical exam. For example, “Thank you for answering my questions. I have finished the interrogation and now I would like to examine you if you don’t mind?
  • Wash your hands or wear globes (faster choice and totally acceptable).
  • Be gentle. Patients will tell you if they have pain even with the slightest touch.
  • Do not perform breast, genital, rectal exams or corneal reflex. Follow the USMLE indications.
  • Say thank you when a patient does something you asked her/him to do.
  • Be attentive to the simulated symptoms such as thoracic movement without actual movement of air into the lungs pointing to decreased breath sounds in the area of auscultation.

Since the physical exam should be focused, it is recommended to review the required physical exam recommended for each chief complaint as described in the Step 2 CS blue sheet cases section of this website. Step 2 CS Blue Sheet Cases CLOSURE The final step in the examination room should be the closure in which we give a clear diagnostic impression to the patient, recommend what can be done such as workup and medical instructions regarding diet, smoking cessation, avoidance of alcohol, etc.

  • The closure should be simple and in plain English depending on the patient’s level of education.
  • Do not forget to ask, “Do you have any question for me?” One does not need to provide a definitive diagnosis during the closure – that usually is not feasible to make.
  • Therefore, give your opinion to your patient about all the possible causes from the most probable to the least, outlining what is your recommendation to reach a final diagnosis is and clarifying any question or concern the patient may have regarding his health.

This finishes the clinical history taking section of the USMLE Step 2 CS exam. The key for the USMLE Step 2 CS exam is to practice over and over the cases, ideally with a real person (study partner or anyone else). Please, if you have any comment, question, or suggestion, do not hesitate to write it down in the comments section below.

SCIENCE REVEALS THE POWER OF A HANDSHAKE by Steve McGaughey.

  • Author
  • Recent Posts

Hematology/Oncology Fellow at BUSM | Former Internal Medicine Residency/Chief Resident at UCONN | Website Developer & Author at Ecuadoctors.com Latest posts by Juan Chango Azanza ( see all )

What is a medication encounter?

Understanding the meaning of medications for patients: the medication experience – PubMed Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers.

The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care.

The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis.

The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience.

The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control.

  • The medication experience is an individual’s subjective experience of taking a medication in his daily life.
  • It begins as an encounter with a medication.
  • It is an encounter that is given meaning before it occurs.
  • The experience may include positive or negative bodily effects.
  • The unremitting nature of a chronic medication often causes an individual to question the need for the medication.

Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.

See also:  Why Is Integrity Important In Healthcare?

What does encounter mean in EMR?

Traits – Traits for this entity are listed below. is.CDM.entityVersion

Parameter Value Data type Explanation
versionNumber “2.1” string semantic version number of the entity

is.CDM.attributeGroup identifies standard groups of attributes in CDM entities.

Parameter Value Data type Explanation
groupList
attributeGroupReference
/core/wellKnownCDSAttributeGroups.cdm.json /cdsCreationModificationDatesAndIds
/core/wellKnownCDSAttributeGroups.cdm.json /cdsOwnershipInfo
/core/wellKnownCDSAttributeGroups.cdm.json /cdsTimeZoneInfo
/core/wellKnownCDSAttributeGroups.cdm.json /cdsVersionTracking
/core/applicationCommon/foundationCommon /crmCommon/accelerators/healthCare /electronicMedicalRecords/Encounter.cdm.json /Encounter/hasAttributes /attributesAddedAtThisScope

/td>

entity

is.identifiedBy names a specifc identity attribute to use with an entity

Parameter Value Data type Explanation
attribute Encounter/(resolvedAttributes)/encounterId attribute

means.entityState the attribute represents the current state of the entity.

Parameter Value Data type Explanation
attribute Encounter/(resolvedAttributes)/stateCode attribute

is.localized.displayedAs Holds the list of language specific display text for an object.

Parameter Value Data type Explanation
localizedDisplayText
languageTag displayText
en Encounter

/td>

entity a reference to the constant entity holding the list of localized text

is.localized.describedAs Holds the list of language specific descriptive text for an object.

Parameter Value Data type Explanation
localizedDisplayText
languageTag displayText
en An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

/td>

entity a reference to the constant entity holding the list of localized text

is.CDS.sourceNamed the unique name that identifies this object in CDS for Applications.

Parameter Value Data type Explanation
name “msemr_encounter” string

What is required to close an encounter in Epic?

Epic – Close Encounters Now that you’re live on Epic it’s essential to understand how to close encounters within 24 hrs. After a successful encounter, close it by finding that encounter in your “In Basket,” go to “My Open Encounters” and click on the “Sign Encounter” button near the top right.

How do you select an encounter in Epic?

Notice the Storyboard displays on the left side of the screen.4. Click Select Encounter from the bottom of the Storyboard.

What does encounter mean in psychology?

The term ‘encounter’, in the context of existential-humanism (like existential therapy), has the specific meaning of an authentic, congruent meeting between individuals.

What word means the same as encounter?

Definitions of encounter. verb. come together. synonyms: come across, meet, run across, run into, see assemble, foregather, forgather, gather, meet. collect in one place.

What are the different types of patient encounters?

8.11.1 Scope and Usage – A patient encounter is further characterized by the setting in which it takes place. Amongst them are ambulatory, emergency, home health, inpatient and virtual encounters. An Encounter encompasses the lifecycle from pre-admission, the actual encounter (for ambulatory encounters), and admission, stay and discharge (for inpatient encounters).

  1. During the encounter the patient may move from practitioner to practitioner and location to location.
  2. Because of the broad scope of Encounter, not all elements will be relevant in all settings.
  3. For this reason, admission/discharge related information is kept in a separate admission component within Encounter.

The class element is used to distinguish between these settings, which will guide further validation and application of business rules. There is also substantial variance from organization to organization (and between jurisdictions and countries) on which business events translate to the start of a new Encounter, or what level of aggregation is used for Encounter.

For example, each single visit of a practitioner during a hospitalization may lead to a new instance of Encounter, but depending on local practice and the systems involved, it may well be that this is aggregated to a single instance for a whole admission. Even more aggregation may occur where jurisdictions introduce groups of Encounters for financial or other reasons.

Encounters can be aggregated or grouped under other Encounters using the partOf element. See below for examples. Encounter instances may exist before the actual encounter takes place to convey pre-admission information, including using Encounters elements to reflect the planned start date or planned encounter locations.

In this case the status element is set to ‘planned’. The admission component is intended to store the extended information relating to an admission event. It is always expected to be the same period as the encounter itself. Where the period is different, another encounter instance should be used to capture this information as a partOf this encounter instance.

The Procedure and encounter have references to each other, and these should be to different procedures; one for the procedure that was performed during the encounter (stored in Procedure.encounter), and another for cases where an encounter is a result of another procedure (stored in Encounter.reason) such as a follow-up encounter to resolve complications from an earlier procedure.

What are the steps of patient encounter?

Objectives: Learn how to address a patient in the Step 2 CS exam, developing a standard way of approaching patients efficiently by using a structured plan for the clinical history, physical exam, closure, and patient note. Use mnemonics to help to guide the examinee during the patient encounter and patient note. Step 2 CS Patient Encounter – Medical History to Closure (With Mnemonics) What Is An Encounter In Healthcare The patient encounter is composed of four major parts: the clinical history taking, physical exam, closure and patient note. It starts with the doorway information and finishes after one has finished typing the patient’s note. The actual encounter with the patient at the examination room determines the final scores of the CIS (Communication and Interpersonal Skills) and the SEP (Spoken English Proficiency) parts of the Step 2 Cs exam.

  • The physical examination and patient note are the two pillars of the ICE (Integrated Clinical Encounter) section.
  • Therefore, learning to approach the patient encounter in a standardized and efficient way is crucial for passing the exam.1.
  • ClINICAL HISTORY TAKING The best aid to use during the exam is the blue sheet of paper that the examination center will provide to the examinees.

Information about how to use this blue sheet as the best helper tool during the exam will be described continuously throughout this publication. Remember to make a transition statement when changing from one part to another. For example, when switching from the past medical history to the history of present illness, one might say, I would like to ask you about your current problem now, please? DOORWAY INFORMATION Before a case starts in the USMLE Step 2 CS exam, basic information about the patient will be described such as the name, age, gender, chief complaint, vital signs (if abnormal), indications for the case, etc.

  1. Making a mental differential diagnosis for the chief complaint that the patient holds. The more focused on the patient the better. For example, a patient with chest pain can have more probability of having a myocardial infarction if his age is >50 years old versus a younger patient.
  2. Writing down important information on the blue sheet that you may forget due to nervousness or lack of time to think during the encounter or patient note. What you can write involves mostly the differential diagnosis and mnemonics.

The time taken at the doorway should be the required for the applicant to be prepared to approach the case with confidence and clarity of mind. The standard time is 10-20 seconds (First Aid). However, in practice, it can take around 45 seconds to a minute to be ready to go in after writing down all one may need.

  • Knock the door before going into the room.
  • Verify the patient’s identity by asking, “Good morning, Mr. Jones?”
  • Keep eye contact as much as possible.
  • Introduce yourself, “Hi, I am Dr. X, nice to meet you.”
  • Shake hands firmly but gently. Do it with confidence and keep eye contact (handshake is important in the United States).
  • Drape the patient (most patients seen in the exam will be already draped).

THE CLINICAL HISTORY There are two ways of taking a clinical history (both of which generally start by asking the patient something like, what brings you in today?:

  1. Starting with the history of present illness (HPI): After asking what can I do for you today? and getting a reply such as, “I feel dizzy,” one can continue asking about the dizziness. Hence, finishing the history of present illness first and then moving on to the past medical history.
  2. Starting with the past medical history (PMH): After asking, how can I help you today? and getting a response like, “I have a headache,” one can transition into the past medical history saying, “I am sorry about that. Please, let me ask you about your background to better understand your current problem, all right? After finishing the PMH, one can continue with the HPI.

Which one is better is up to the examinee. There is an advantage of asking first about the past medical history, which is that you will be more oriented as to what is the most feasible cause of the chief complaint. A hypertensive and diabetic patient experiencing chest pain suggests more a cardiovascular cause comparing to a patient with chest pain and unknown history.

  • Past medical history: Ask about the past medical history, for example, “Have you ever been diagnosed with any medical condition?” Ask all about the disease like when it was diagnosed, for how long it has been present, treatments, and so on.
  • Hospitalizations: Have you ever been hospitalized before?
  • Past surgical history: Have you ever had any surgery in the past?
  • Medications: Are you taking any medications? Ask about prescribed and over the counter drugs.
  • Allergies: Do you have any allergy? Ask about allergies to medications, environmental elements, and the reaction originated from the exposure (eg. rash).
  • Social history: Occupation, diet, exercise. Also, ask about the important 3 bad habits: “SAI” smoking, alcohol and illicit drugs consumption. It is important to ask for when it started, how long it has been going on, the quantity used and the intention or attempts to quit the substance use. One can advise quickly about the advantage of quitting right away at this point, releasing some of the tasks needed to be done at the closure.
  • Sexual history: Ask about sexual behavior, partners, and safety taken.
  • OB/GYN: Ask about obstetric history (gestations, parturitions, abortions, cesareans, etc.) G1P1A0C0. Menstrual cycle, last menstrual period and anything else that you might consider important for the case.
  • Family history: Always ask about the history of the present problem. For example, if a patient is experiencing psychotic symptoms, asking about family history is important to identify a primary psychiatric disorder. Ask about direct family members (parents, brothers, and offspring).

The sexual and OB/GYN history are not always necessary to take. Thus it is at the examinee’s discretion if it is necessary to take them. In case of doubt, it is better to do it superficially unless otherwise required. It is NOT necessary to use mnemonics for the past medical history.

  1. The reason is that the PMH is done almost in the same way for all cases and if practiced frequently enough, one will probably memorize it with ease.
  2. However, a mnemonic such as PAM HUGS FOSS can be used.
  3. HISTORY OF PRESENT ILLNESS (HPI) One can start with the chief complaint and then continue asking in detail what is relevant.

Do not forget to show compassion when a patient states experiencing a symptom such as pain. A simple phrase like, “I am sorry that you are experiencing this pain” or “That must be difficult for you” helps to build rapport with the patients. Using a mnemonic is recommended for the history of present illness.

  • A: Antiquity or age. Refers to the antiquity or age of the current problem. This letter has its own mnemonic P-OCDPSF
    • P: Prior events.
    • O: Onset. When did it start?
    • C: Constant or intermittent. Is the problem always present or does it comes and goes?
    • D: Duration. If constant ask when it started. If intermittent (episodic), ask when did the episodes started and how long they last.
    • P: Progression. Is the current problem worsening, the same, or getting better.
    • S: Setting in which it occurs. What were you doing when the pain started?
    • F: Frequency. How many times a day, week, or month does it occur?
  • L: Localization of the symptom such as pain.
  • I: It travels through the body or not? Radiation of the pain.
  • C: Characteristic of the pain. Is the pain sharp or dull?
  • I: Intensity. On a scale of 1 to 10, how would you rate your pain/symptom?
  • A: Aggravating and alleviating factors (two A’s). What makes it better? What makes it worse?
  • A: Associated symptoms with it.

REVIEW OF SYSTEMS (ROS): The review of systems should be focused on the current problem and special case needs. For example, a patient presenting with fatigue needs to be asked about the presence of constitutional symptoms. Therefore, learning a few short mnemonics for such cases may help: To screen for constitutional symptoms, infections, and other systemic disorders: WFA mnemonic

  • W: Weight loss or gain (unintentional).
  • F: Fever or chills.
  • A: Appetite changes such as anorexia.

To screen for thyroid disorders: C-C-H/S mnemonic

  • C: Constipation or diarrhea.
  • C: Cold or heat intolerance.
  • H/S: Hair and/or skin changes such as dry skin or alopecia.

To screen for neuropathic damage and neurologic disorders such as stroke T-N-W mnemonic

  • T: Tingling (sensory nerve disorder).
  • N: Numbness (sensory nerve disorder).
  • W: Weakness (motor abnormalities).

Tingling, numbness, and weakness should be asked together if possible. They screen for neuropathy and motor abnormalities. There are other very important mnemonics that are useful in specific cases. They are described in every chief complaint described in the Step 2 CS publications on this website.

  • Make a transition statement when planning to start the physical exam. For example, “Thank you for answering my questions. I have finished the interrogation and now I would like to examine you if you don’t mind?
  • Wash your hands or wear globes (faster choice and totally acceptable).
  • Be gentle. Patients will tell you if they have pain even with the slightest touch.
  • Do not perform breast, genital, rectal exams or corneal reflex. Follow the USMLE indications.
  • Say thank you when a patient does something you asked her/him to do.
  • Be attentive to the simulated symptoms such as thoracic movement without actual movement of air into the lungs pointing to decreased breath sounds in the area of auscultation.

Since the physical exam should be focused, it is recommended to review the required physical exam recommended for each chief complaint as described in the Step 2 CS blue sheet cases section of this website. Step 2 CS Blue Sheet Cases CLOSURE The final step in the examination room should be the closure in which we give a clear diagnostic impression to the patient, recommend what can be done such as workup and medical instructions regarding diet, smoking cessation, avoidance of alcohol, etc.

  • The closure should be simple and in plain English depending on the patient’s level of education.
  • Do not forget to ask, “Do you have any question for me?” One does not need to provide a definitive diagnosis during the closure – that usually is not feasible to make.
  • Therefore, give your opinion to your patient about all the possible causes from the most probable to the least, outlining what is your recommendation to reach a final diagnosis is and clarifying any question or concern the patient may have regarding his health.

This finishes the clinical history taking section of the USMLE Step 2 CS exam. The key for the USMLE Step 2 CS exam is to practice over and over the cases, ideally with a real person (study partner or anyone else). Please, if you have any comment, question, or suggestion, do not hesitate to write it down in the comments section below.

SCIENCE REVEALS THE POWER OF A HANDSHAKE by Steve McGaughey.

  • Author
  • Recent Posts

Hematology/Oncology Fellow at BUSM | Former Internal Medicine Residency/Chief Resident at UCONN | Website Developer & Author at Ecuadoctors.com Latest posts by Juan Chango Azanza ( see all )

Adblock
detector