Doctor-Patient Encounter

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As physicians, the patient-encounter is a routine process that we hardly analyze in a scientific manner. But the physician-patient encounter is extremely important from the perspective of health management information systems. Though the workflow and thought-flow may vary based on the setting, individual and specialty, I have tried to summarize basic steps in a physician-patient encounter.

Initially there will be a rapport building phase for new patients which naturally will be unstructured. This is followed by history taking and clinical examination. A physician may take notes during this process, but the information on his notes generally will be semi-structured. This information is transcribed into the EMR in a fully structured form though free form text may be needed to capture certain elements.

Physician patient encounter
The basic steps in a physician-patient encounter 

The physician arrives at a list of probable diagnosis (differentials) following which the physician may go back to history taking and examination to find more clues for a definitive diagnosis. Clinical decision support systems (CDSS) may be useful during this phase. Physician requests  investigations and comes to a more specific diagnosis.

Management starts with a specific diagnosis in most cases. CDSS helps during this phase along with computerized physician order entry (CPOE) and ePrescription. When the patient comes for follow-up, these steps are repeated and the initial diagnosis is re-evaluated.

Cite this article as: Eapen BR. (May 7, 2015). Nuchange.ca - Physician-patient encounter for HMIS & eHealth. Retrieved April 18, 2024, from https://nuchange.ca/2015/05/physician-patient-encounter-for-hmis-ehealth.html.

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