EPA 1A: Obtain a Patient History
SCOPE OF WORK: This activity includes gathering chief concern, general health, medications, oral health, and personal/ psychosocial factors for comprehensive and periodic visits.
Domains of Competence
- Person-Centered Care
- Critical Thinking and Decision Making
- Biomedical Science Application
Knowledge
- Components of patient history
- Disease processes
- How to access appropriate and reliable resources to address knowledge gaps (e.g., UpToDate)
- Branching tree questioning process
- Strategies for effective communication with diverse populations
- Required documentation of patient history components in electronic patient record (Epic Wisdom)
Skills
- Effective communication, including developing patient rapport and trust
- Apply knowledge of disease processes to identify appropriate information needed
- Identify relevant/essential information for diagnosis, treatment planning, and determining outcomes
- Identify gaps in knowledge and appropriate resources (e.g., UpToDate)
- Apply critical thinking skills to distinguish relevant information
- Use branching tree questioning process to decide when and how to explore further
- Properly document elements/components of patient history in electronic patient record (Epic Wisdom)
| Obtain a Patient History |
Meets Expectations of the Graduate
|
Progressing
|
Below Expectations
|
Critical Error
|
|---|---|---|---|---|
| Identification and Recording of Chief Concern | Correctly identifies and records chief concern and all significant general health, oral health, and psychosocial problems | Correctly identifies and records chief concern, general health, oral health, but may omit some details or leave out psycho-social issues | Identifies and records chief concern, but fails to identify significant general health, oral health and/or psycho-social problems | Fails to identify and record patient’s chief concern or any potentially lifethreatening medical problems |
| INFORMATION GATHERING |
Obtains a thorough, accurate history in an organized and systematic manner using person-centered communication1
|
Obtains most of the pertinent information; flow is generally organized and systematic; communication skills are predominantly person-centered | Fails to obtain the patient history in an organized, systematic manner, or to utilize person-centered communication, leading to incomplete pertinent information | Fails to obtain critical information from patient history |
1 Refer to Standardized Patient Encounter Communications Skills Rubric (Used by SP)
Ratings on "Person-Centered Care" and "Documentation" for this encounter will be included for the assessment of this task.