How to be UKSAC Interviewer

Arrive at the clinic at 5:30. Bring back 1^st patient at 5:40 if new pt, 5:50 if returning pt.

Most common supplies are kept in the waist-high cabinets in each exam room.

Always ask the FM if you have questions or needs.

To chart NEW PATIENTS:

- Get the consent form and tracking forms filled out (on the right side). 

- Interview and examine the pt according to the standard form for first encounters (right).

- After documentation, sign the form, print your name, and note your classification.

- Note any allergies, medical conditions, and medications on the form to the left.

- Also note allergies on the sticker on the outside of the chart.

To chart RETURNING PATIENTS:

- Fill out a progress report form (blank sheet with lines) in the SOAP note format:

S=Subjective: symptoms, what the patient says, relevant HPI, PMH, FMH, SH

            O=Objective: physical signs, physical exam findings, tests, labs

            A=Assessment: diagnosis or list of symptoms, discussion of reasoning

            P=Plan: treatment, meds (OTC or prescription), therapy, follow-up

- Sign your documentation with your name, print your name, and note your classification.

- Note any new allergies, medical conditions, and medications on the form to the left.

PRESENT TO THE ATTENDING after your interview is complete. Gather your thoughts so that you can give the relevant information systematically. Physician preferences will vary, but you can roughly follow the SOAP note order. An example:

“Mr. Q is a 40yo Asian male with intense chest pain upon exercise that typically lasts 15-20 minutes. He has CAD and HTN, is obese, has smoked 2 ppd for 20 years, and his father died of heart attack at 52. He is prescribed HCTZ but cannot afford it. BP was 200/100, pulse 88, heart sounds normal.”

- Answer any further questions the Attending has.

- Accompany the Attending back to the exam room for the secondary interview.

- Run necessary labs in the lab area; document in the patient’s chart and the Labs binder.

- Get necessary medications from the Pharmacy cabinet; document in the Pharm binder.

- Make any Social Services referrals in cooperation with the FM.

- Make sure the Attending signs the chart at the end of documentation.

- Thank the patient and escort them out.

- Document your case in the Floor Manager’s Log, then give the chart to the FM.

ABBREVIATIONS

BP = blood pressure                                                                            Hx = history

CAD = coronary artery disease                                                         PMH = past medical history

CC = chief complaint                                                                           RR = respiratory rate

COPD = chronic obstructive pulmonary disease                            RTC = return to clinic

DM = diabetes mellitus                                                                       Sx = symptom

HA = heart attack

HPI = history of present illness

HR = heart rate

HTN = hypertension