Initial Approach to Establishing Care for a New Patient
A complete medical evaluation should be performed at the initial visit to confirm diagnosis, evaluate for complications and comorbidities, review previous treatments, begin patient engagement in care management planning, and develop a plan for continuing care 1.
Components of the Initial Comprehensive Assessment
Medical History
- Present and past medical history, including:
- Chronic conditions (diabetes, hypertension, heart disease, etc.)
- Previous hospitalizations and surgeries
- Current symptoms and their duration
- Previous diagnoses and treatments
- Medication history (prescription, over-the-counter, supplements)
- Allergies and adverse reactions
- Immunization status 1
Risk Assessment
- Family history of diseases
- Social history:
- Tobacco, alcohol, and substance use
- Diet and exercise habits
- Occupation and environmental exposures
- Living situation and social support
- Sleep patterns (poor sleep quality associated with worse outcomes) 1
- Social determinants of health that may affect care 1
Physical Examination
- Comprehensive physical examination including:
- Vital signs (blood pressure, heart rate, respiratory rate, temperature)
- Height, weight, and BMI calculation
- Cardiovascular, respiratory, abdominal, neurological, and musculoskeletal examinations
- Skin examination
- Fundoscopic examination (or referral to eye specialist) 1
Laboratory and Diagnostic Testing
- Basic laboratory tests based on age, risk factors, and medical history:
- Complete blood count
- Comprehensive metabolic panel
- Lipid profile
- Urinalysis
- Hemoglobin A1C (for diabetes risk)
- Additional tests as indicated by history and physical findings 1
Psychosocial Assessment
- Screen for:
- Depression and anxiety
- Cognitive impairment (especially in older adults)
- Functional performance
- Substance use disorders
- Disordered eating 1
Decision-Making Capacity Assessment
- Evaluate the patient's ability to:
- Take in information
- Understand its meaning
- Make informed decisions based on the information 1
Preventive Care Planning
- Immunization review and planning:
- Ensure age-appropriate vaccinations are up to date
- Annual influenza vaccination
- Pneumococcal vaccination as appropriate
- Hepatitis B vaccination as indicated 1
- Cancer screenings based on age and risk factors
- Cardiovascular risk assessment using appropriate tools 1
Communication Strategies
- Use empowering, non-judgmental language 1
- Establish collaborative relationship with the patient 1
- Assess the patient's understanding of their health conditions 1
- Provide information in simple, direct terms using multiple formats 1
- Check for patient understanding and document important discussions 1
Care Plan Development
- Prioritize goals based on medical necessity and patient preferences
- Outline intervention strategies for risk reduction
- Create a follow-up plan that reflects progress toward goals
- Ensure appropriate medication management 1
Follow-Up Planning
- Schedule appropriate follow-up visits:
- At least every 3-6 months for patients with chronic conditions
- Annually for routine preventive care 1
- Ensure continuity of care with appropriate referrals to specialists as needed
Common Pitfalls to Avoid
- Rushing through the initial assessment
- Failing to establish rapport before discussing sensitive topics
- Overreliance on laboratory tests without thorough history and physical examination 2, 3
- Neglecting to assess social determinants of health
- Missing opportunities for preventive interventions
- Poor documentation that hampers continuity of care
By following this structured approach to establishing care, providers can ensure comprehensive assessment, appropriate diagnosis, and effective treatment planning that prioritizes patient outcomes in terms of morbidity, mortality, and quality of life.