BATES CHAPTER 1
• Approach to clinical encounter
o Clinician centered – focuses on need to get info about pt symptoms and other details to identify
disease
o Patient centered – considers patient concerns feelings, and emotions to get personal context on
symptoms and disease
o Disease – explanation used by clinician to organize symptoms to establish diagnosis
o Illness – explains how the patient experiences disease
▪ Effects on relationships, function, and sense of wellbeing
• Clinical encounter sequence
1. Initiating encounter
• Settings stage
• Building trust and rapport – initial moments lay foundation
• Set goals
• Children – involve by asking age-appropriate questions
• Adolescents – allow them to answer first and tell parents they will have a chance to speak as well,
acknowledge confidentiality with child
2. Gathering info
• Chief complaint, present problem – reason why seeking care
• Do not interrupt pt – allow to finish story then ask detail questions
• FIFE – feelings, ideas, effects on function, expectations
o Helps find patient perspective on illness
• Past medical history, family history, personal/social history, review of symptoms
3. Physical exam
o Complex head to toe vs. Focused assessment
4. Explaining and planning
o Teach back or show me – see how well you taught, not how much they got wrong
o Shared decision making
▪ Introducing choices and describing options
▪ Exploring patient preferences
▪ Move toward decision when pt is ready and offer more time if needed
5. Closing encounter
o Avoid bringing up new topics
• Healthcare disparities
o Social determinants
▪ Stress, early life, social exclusion working conditions, unemployment, social support,
addiction, healthy food, transportation
o Implicit bias – Subconscious stereotypes
o Explicit bias – deliberate decisions/preferences
o 5 R’s of cultural humility
▪ Reflection, Respect, Regard, Relevance, Resiliency
• Other considerations
o Spirituality – way to seek and express meaning and purpose
o Religion – specific beliefs common to a community in r/t higher power
o Medical ethics
▪ Nonmalificence – do no harm
▪ Beneficence – acts for pt good by preventing or treating disease
, ▪ Respect for autonomy – accepts choices of pt about treatment
▪ Decisional capacity – ability to make autonomous choice
▪ Confidentiality – duty to prevent disclosing private info
▪ Informed consent – pt voluntary and knowledgeable authorization to treat/test
▪ Truth telling – clinician should give info beyond informed consent requirements relevant to pt
▪ Justice – all pt with similar needs should receive similar treatment
o Capacity – clinical decision, assessed by clinician
o Competency – judicial determination decided only in court
o Aid to Capacity Evaluation (ACE)
o Ethical dilemma resolution
a. Clearly state ethical question
b. Collect relevant info
1. Diagnosis, prognosis, pt preference, pt goal of care
2. Religion, financial resources, concerns of stakeholders
c. Identify ethical principles and guidelines
1. Laws and institutional policies
d. Delineate and relate options to values and principles
1. If principle X is primary, then action Y is justified
e. Evaluate different options with justifications
f. Make action plan
BATES BCHAPTER 2
• Fundamentals of skilled interviews
o Active/attentive listening
▪ Carefully attending to what pt is communicating, connecting iwth what pt feeling, and using
verbal and nonverbal skills to facilitate pt to expand on feelings and concerns
o Guided questioning
▪ Goal is to facilitate full communication in pt own words without interruption
▪ Work from open-ended questions to quantifying questions to yes or no questions
▪ Avoid leading questions
▪ Ask questions with graded response
▪ One question at a time
▪ Minimize bias with multiple choice
▪ Do not be afraid to ask for clarification
▪ Repeat pt last words – echoing – to encourage elaboration
o Empathy – ability to relate and feel pr pain as your own and respond with support
o Reassurance – 1st step is identifying and acknowledging pt feelings
• Appropriate verbal communication
o Use understandable language
▪ Avoid medical jargon, abbreviations, complex words/statements
o People first language
▪ Suggest person might have condition/illness, but not described by it
• Advanced directives
o POLST/MOLST
▪ Actionable medical order explaining medical orders r/t life-sustaining treatment
o DNR
▪ Education pt and family on likelihood of CPR success
, o SPIKES protocol for disclosing serious news
▪ Setting up interview
▪ Assessing pt Perspective
▪ Obtaining pt Invitation
▪ Giving Knowledge and info
▪ Addressing pt Emotions with Empathy
▪ Strategy and Summary
BATES CHAPTER 3
• Health history
o Comprehensive vs. Focused
o Subjective – what pt tells you
o Objective – findings clinician detects, labs, diagnostic tests
• Comprehensive adult health history
o Chief complaint
▪ Primary problem prompting pt to be seen
▪ Try to quote pt own words when documenting
o History of present illness
▪ Concise, clear, chronological description of CC
▪ OLD CARTS – onset, location, duration, character, aggravating/alleviating factors, radiation,
timing, setting/severity
▪ OPQRST – onset, precipitating/palliating factors, quality, region/radiation, severity, timing
▪ Opening statement – CC stated within clinical context
▪ Elaboration – chronological account of events
• Pay attention to timing of symptoms
▪ Pertinent positives – any symptom possibly r/t CC
▪ Pertinent negatives – symptoms not present r/t possible diagnosis
▪ End with how and why pt seeking medical care
o Past medical history
▪ All active/past medical problems
▪ Childhood and adult – medical, surgical, psychiatric, OB/GYN
▪ Immunizations, age-appropriate preventative measures (colonoscopy/mammogram)
▪ Allergies with specific reaction to med or food
• Adverse reaction – noxious, unintended response to drug at normal dose
• Allergy – adverse reaction mediated by immune response
• Side effect – expected known effect of drug but not intended therapeutic outcome
▪ Medications – all prescription, OTC, vitamins, mineral/herbal supplements, eye drops,
ointments, oral contraceptives, home remedies, meds borrowed to take
▪ Family history – health info of immediate family (parents, grandparents, siblings, children,
grandchildren)
▪ Personal history – sexual orientation gender identification, birthplace, occupation, education,
relationships and safety in them, life experiences, leisure activities, sexuality, spirituality,
social support systems, baseline ADLs
• FICA Spirituality Tool – Faith/beliefs, Importance/Influence, Community, Address
▪ Social history – tobacco, illicit drugs, alcohol abuse, habits that promote health or create risk
• 5 P’s to sexual history – Partners, Practice, STI Protection, STI Past history, Pregnancy
Prevention
, o Review of Symptoms
▪ Series of questions from head to toe
• Record findings
o Clear, concise, comprehensive report
BATES CHAPTER 4
• Comprehensive adult physical exam
o Good lighting, quite environment
o Standard precautions
▪ All blood, bodily fluids, secretions, excretions (except sweat), nonintact skin, mucous
membranes may contain transmissible infectious agents
▪ Hand hygiene
▪ PPE – gown, gloves, mouth/nose/eye protection
▪ Safe injection practices
▪ Respiratory hygiene and cough etiquette
▪ Isolation criteria
▪ Precautions r/t equipment, toys, solid surfaces, laundry
o Universal precautions – BOX 4-6
▪ Prevent parenteral, mucous membrane, and noncontact exposure of clinician to bloodborne
pathogens
▪ Gloves, gown, apron, mask, protective eyewear
o 4 classic techniques – inspection, palpation, percussion, auscultation (in order)
▪ Except abdomen – inspection, auscultation, palpation, percussion
o 3 goals
▪ Maximize pt comfort
▪ Avoid unnecessary position changes
▪ Enhance clinical efficiency
o Recommend examining from RIGHT SIDE and moving if necessary
• Head to Toe Exam – PAGE 126-129
BATES CHAPTER 5
• Clinical Reasoning, Assessment, Plan
o Dual processing – two thought processes when making decisions
o System 1 – intuitive system
▪ Fast, automatic reaction to information that functions on mental shortcuts
• Heuristics – formulaic patterns based on formed habits
▪ Difficult to change or manipulate
▪ Clinician relies on experience
▪ Diagnose rapidly with little effort – less reliable and common errors
o System 2 – hypotheticodeductive system
▪ Subject to conscious judgments and attitudes, uses logic and probabilities to make
conclusions
▪ More tempered, controlled thought process
▪ More consideration, time and effort – greater reliability, fewer errors
o Start with gathering info from pt
▪ Symptoms from history, signs from exam, any lab results and diagnostics tests
o Organize and interpret info with goal of creating concise, appropriate “problem representation”
• Approach to clinical encounter
o Clinician centered – focuses on need to get info about pt symptoms and other details to identify
disease
o Patient centered – considers patient concerns feelings, and emotions to get personal context on
symptoms and disease
o Disease – explanation used by clinician to organize symptoms to establish diagnosis
o Illness – explains how the patient experiences disease
▪ Effects on relationships, function, and sense of wellbeing
• Clinical encounter sequence
1. Initiating encounter
• Settings stage
• Building trust and rapport – initial moments lay foundation
• Set goals
• Children – involve by asking age-appropriate questions
• Adolescents – allow them to answer first and tell parents they will have a chance to speak as well,
acknowledge confidentiality with child
2. Gathering info
• Chief complaint, present problem – reason why seeking care
• Do not interrupt pt – allow to finish story then ask detail questions
• FIFE – feelings, ideas, effects on function, expectations
o Helps find patient perspective on illness
• Past medical history, family history, personal/social history, review of symptoms
3. Physical exam
o Complex head to toe vs. Focused assessment
4. Explaining and planning
o Teach back or show me – see how well you taught, not how much they got wrong
o Shared decision making
▪ Introducing choices and describing options
▪ Exploring patient preferences
▪ Move toward decision when pt is ready and offer more time if needed
5. Closing encounter
o Avoid bringing up new topics
• Healthcare disparities
o Social determinants
▪ Stress, early life, social exclusion working conditions, unemployment, social support,
addiction, healthy food, transportation
o Implicit bias – Subconscious stereotypes
o Explicit bias – deliberate decisions/preferences
o 5 R’s of cultural humility
▪ Reflection, Respect, Regard, Relevance, Resiliency
• Other considerations
o Spirituality – way to seek and express meaning and purpose
o Religion – specific beliefs common to a community in r/t higher power
o Medical ethics
▪ Nonmalificence – do no harm
▪ Beneficence – acts for pt good by preventing or treating disease
, ▪ Respect for autonomy – accepts choices of pt about treatment
▪ Decisional capacity – ability to make autonomous choice
▪ Confidentiality – duty to prevent disclosing private info
▪ Informed consent – pt voluntary and knowledgeable authorization to treat/test
▪ Truth telling – clinician should give info beyond informed consent requirements relevant to pt
▪ Justice – all pt with similar needs should receive similar treatment
o Capacity – clinical decision, assessed by clinician
o Competency – judicial determination decided only in court
o Aid to Capacity Evaluation (ACE)
o Ethical dilemma resolution
a. Clearly state ethical question
b. Collect relevant info
1. Diagnosis, prognosis, pt preference, pt goal of care
2. Religion, financial resources, concerns of stakeholders
c. Identify ethical principles and guidelines
1. Laws and institutional policies
d. Delineate and relate options to values and principles
1. If principle X is primary, then action Y is justified
e. Evaluate different options with justifications
f. Make action plan
BATES BCHAPTER 2
• Fundamentals of skilled interviews
o Active/attentive listening
▪ Carefully attending to what pt is communicating, connecting iwth what pt feeling, and using
verbal and nonverbal skills to facilitate pt to expand on feelings and concerns
o Guided questioning
▪ Goal is to facilitate full communication in pt own words without interruption
▪ Work from open-ended questions to quantifying questions to yes or no questions
▪ Avoid leading questions
▪ Ask questions with graded response
▪ One question at a time
▪ Minimize bias with multiple choice
▪ Do not be afraid to ask for clarification
▪ Repeat pt last words – echoing – to encourage elaboration
o Empathy – ability to relate and feel pr pain as your own and respond with support
o Reassurance – 1st step is identifying and acknowledging pt feelings
• Appropriate verbal communication
o Use understandable language
▪ Avoid medical jargon, abbreviations, complex words/statements
o People first language
▪ Suggest person might have condition/illness, but not described by it
• Advanced directives
o POLST/MOLST
▪ Actionable medical order explaining medical orders r/t life-sustaining treatment
o DNR
▪ Education pt and family on likelihood of CPR success
, o SPIKES protocol for disclosing serious news
▪ Setting up interview
▪ Assessing pt Perspective
▪ Obtaining pt Invitation
▪ Giving Knowledge and info
▪ Addressing pt Emotions with Empathy
▪ Strategy and Summary
BATES CHAPTER 3
• Health history
o Comprehensive vs. Focused
o Subjective – what pt tells you
o Objective – findings clinician detects, labs, diagnostic tests
• Comprehensive adult health history
o Chief complaint
▪ Primary problem prompting pt to be seen
▪ Try to quote pt own words when documenting
o History of present illness
▪ Concise, clear, chronological description of CC
▪ OLD CARTS – onset, location, duration, character, aggravating/alleviating factors, radiation,
timing, setting/severity
▪ OPQRST – onset, precipitating/palliating factors, quality, region/radiation, severity, timing
▪ Opening statement – CC stated within clinical context
▪ Elaboration – chronological account of events
• Pay attention to timing of symptoms
▪ Pertinent positives – any symptom possibly r/t CC
▪ Pertinent negatives – symptoms not present r/t possible diagnosis
▪ End with how and why pt seeking medical care
o Past medical history
▪ All active/past medical problems
▪ Childhood and adult – medical, surgical, psychiatric, OB/GYN
▪ Immunizations, age-appropriate preventative measures (colonoscopy/mammogram)
▪ Allergies with specific reaction to med or food
• Adverse reaction – noxious, unintended response to drug at normal dose
• Allergy – adverse reaction mediated by immune response
• Side effect – expected known effect of drug but not intended therapeutic outcome
▪ Medications – all prescription, OTC, vitamins, mineral/herbal supplements, eye drops,
ointments, oral contraceptives, home remedies, meds borrowed to take
▪ Family history – health info of immediate family (parents, grandparents, siblings, children,
grandchildren)
▪ Personal history – sexual orientation gender identification, birthplace, occupation, education,
relationships and safety in them, life experiences, leisure activities, sexuality, spirituality,
social support systems, baseline ADLs
• FICA Spirituality Tool – Faith/beliefs, Importance/Influence, Community, Address
▪ Social history – tobacco, illicit drugs, alcohol abuse, habits that promote health or create risk
• 5 P’s to sexual history – Partners, Practice, STI Protection, STI Past history, Pregnancy
Prevention
, o Review of Symptoms
▪ Series of questions from head to toe
• Record findings
o Clear, concise, comprehensive report
BATES CHAPTER 4
• Comprehensive adult physical exam
o Good lighting, quite environment
o Standard precautions
▪ All blood, bodily fluids, secretions, excretions (except sweat), nonintact skin, mucous
membranes may contain transmissible infectious agents
▪ Hand hygiene
▪ PPE – gown, gloves, mouth/nose/eye protection
▪ Safe injection practices
▪ Respiratory hygiene and cough etiquette
▪ Isolation criteria
▪ Precautions r/t equipment, toys, solid surfaces, laundry
o Universal precautions – BOX 4-6
▪ Prevent parenteral, mucous membrane, and noncontact exposure of clinician to bloodborne
pathogens
▪ Gloves, gown, apron, mask, protective eyewear
o 4 classic techniques – inspection, palpation, percussion, auscultation (in order)
▪ Except abdomen – inspection, auscultation, palpation, percussion
o 3 goals
▪ Maximize pt comfort
▪ Avoid unnecessary position changes
▪ Enhance clinical efficiency
o Recommend examining from RIGHT SIDE and moving if necessary
• Head to Toe Exam – PAGE 126-129
BATES CHAPTER 5
• Clinical Reasoning, Assessment, Plan
o Dual processing – two thought processes when making decisions
o System 1 – intuitive system
▪ Fast, automatic reaction to information that functions on mental shortcuts
• Heuristics – formulaic patterns based on formed habits
▪ Difficult to change or manipulate
▪ Clinician relies on experience
▪ Diagnose rapidly with little effort – less reliable and common errors
o System 2 – hypotheticodeductive system
▪ Subject to conscious judgments and attitudes, uses logic and probabilities to make
conclusions
▪ More tempered, controlled thought process
▪ More consideration, time and effort – greater reliability, fewer errors
o Start with gathering info from pt
▪ Symptoms from history, signs from exam, any lab results and diagnostics tests
o Organize and interpret info with goal of creating concise, appropriate “problem representation”
