Acquiring a clinical history and interviewing a patient provides important information for determining a diagnosis and also establishes a solid foundation for the relationship between a clinician and the patient.

An appointment begins with an interview of the patient, when a clinician compiles a patient’s medical history or verifies that the details of the patient’s history already contained in the patient’s medical record are accurate. A patient’s clinical history includes documentation of the current concern, past medical history, family history, social history, and other relevant information, such as current medications (prescription and over-the-counter) and dietary supplements.

The process of acquiring a clinical history and interviewing a patient requires effective communication, active listening skills, and tailoring communication to the patient based on the patient’s needs, values, and preferences.

As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

The physical exam is a hands-on observational examination of the patient. First, a clinician observes a patient’s demeanor, complexion, posture, level of distress, and other signs that may contribute to an understanding of the health problem (Davies and Rees, 2010). If the clinician has seen the patient before, these observations can be weighed against previous interactions with the patient.

A physical exam may include an analysis of many parts of the body, not just those suspected to be involved in the patient’s current complaint. A careful physical exam can help a clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing, and can aid in building trust with the patient (Verghese, 2011).

As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

Clinicians may refer to or consult with other clinicians (formally or informally) to seek additional expertise about a patient’s health problem. The consult may help to confirm or reject the working diagnosis or may provide information on potential treatment options. If a patient’s health problem is outside a clinician’s area of expertise, he or she can refer the patient to a clinician who holds more suitable expertise. Clinicians can also recommend that the patient seek a second opinion from another clinician to verify their impressions of an uncertain diagnosis or if they believe that this would be helpful to the patient. Patients may independently choose to seek a second opinion if they feel their initial diagnosis may not be right.

As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

Diagnostic testing may occur in successive rounds of information gathering, integration, and interpretation, as each round of information refines the working diagnosis. In many cases, diagnostic testing can confirm a diagnosis that is suspected on the basis of the history and physical examination, such as obtaining an electrocardiogram to confirm the diagnosis of a heart attack in a patient with chest pains. There are many important forms of diagnostic testing including laboratory medicine, anatomic pathology, medical imaging and others.

As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.