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1. Obtains the Chief Complaint 2. Asks the appropriate questions related to the the CC and expands the HPI 3. Gathers pertinent past medical history, ROS, Family, Psychosocial 4. Performs Physical Exam Using the appropriate techniques a. Inspection b. Palpation c. Percussion d. Auscultation
Report should have following components: SUBJECTIVE 1. Biographical Sketch 2. Chief complaint or reason for visit 3. Patient Hx using initals and no identifying number 4. Previous illnesses and/or surgeries 5. Review of System OBJECTIVE 1. Results of physical exam. 2. Any followup action plan or tests
Effective professional communication