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Knock on door before entering Say their name using Mr. and Mrs. (NOT first names) and make eye contact Shake hands Drape patient from waist down – down – ask: ask: “Can I make you more comfortable?” Sit down – down – ask: ask: “Do you mind if I sit and take notes?” Ask what problem is, immediately say: “I’m sorry to hear that” History and relevant ROS o Including: ROS: Weight changes Appetite changes Diet Exercise Stress Sleep Drug allergies Past medical history Past surgical history Family history (if relevant) Social history: Occupation Alcohol use Tobacco Drug use
Ensure proper draping Use hand sanitizer and clean stethoscope stethoscope with alcohol swab
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Explain tests you will order and likely diagnosis
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Partners o “Do you have sex with men, m en, women, or both?” o “In the past 12 months, how many ma ny partners have you had sex with?” o “Is it possible that any of your sex partners in the past 12 months have had sex with someone else while they were still in a sexual relationship with you?” Prevention of pregnancy o “What are you doing to prevent pregnancy?” Protection from STIs o “What do you do to protect yourself from STIs and HIV? Practices (preamble: ) o “Have you had vaginal sex, meaning ‘penis-in‘penis-in-vagina’ vagina’ sex?” If yes “Do you use condoms: never, sometimes, or always?” o “Have you had anal sex, meaning ‘penis-in‘penis-in-rectum/anus’ rectum/anus’ sex?” nev er, sometimes, or If yes “Do you use condoms: never, always?” o “Have you had oral sex, meaning ‘mouth-on‘mouth-onpenis/vagina’?” Past STI history o “Have you ever had a sexually transmitted transmitted infection?” o “Have any of your partners had a sexually transmitted infection?” Additional questions questions to identify HIV and viral hepatitis risk o “Have you or any of your partners ever injected drugs?” o “Have you or any of your partners exchanged money or drugs for sex?”
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Can you state your name? How old are you? Where are you right now? Repeat the 3 words I’m going to tell you right now, and then I’m going to ask you to do so again a little later. Who is the current president? (Point at object, ask patient to name it) Can you spell the word “cat” backwards? Repeat the 3 words I asked you earlier.
Have you ever felt you should on your drinking? Have people you by criticizing your drinking? Have you ever felt bad or about your drinking? Have you ever taken a drink first thing in the morning ( ) to steady your nerves or get rid of a hangover?
(Report CAGE on the note section based on results, e.g. “CAGE 3/4” 3/4” if 3 of above questions are answered in the positive, “CAGE 0/4” 0/4” if all answered in the negative, etc.)
