What is the recommended approach for a new patient visit?

New Patient Visit: Recommended Approach

For a new patient visit, perform a comprehensive medical evaluation that confirms or establishes the diagnosis, evaluates for complications and comorbidities, reviews prior treatments if applicable, engages the patient in collaborative care planning, and establishes a framework for ongoing management. 1

Core Components of the Initial Visit

Medical History Assessment

• Document the presenting concern including onset characteristics, duration, and severity of symptoms 1
• Obtain family history of relevant conditions, particularly for chronic diseases like diabetes where family patterns inform risk stratification 1
• Review medication history including previous treatment regimens, responses, adherence patterns, and any intolerances or side effects 1
• Assess psychosocial context including cultural factors, socioeconomic barriers, emotional well-being, and support systems that impact treatment adherence 1

The medical history is the highest-yield component of diagnosis, establishing the correct diagnosis in approximately 76% of cases, compared to 12% from physical examination and 11% from laboratory testing 2. This evidence base supports prioritizing a thorough history over reflexive test ordering.

Physical Examination

• Perform a targeted physical examination based on the presenting complaint and differential diagnosis 1
• Obtain vital signs including blood pressure, heart rate, temperature, and weight 1
• Document specific findings relevant to the suspected diagnosis and potential complications 1

While physical examination contributes to diagnosis in only 12% of cases, it significantly increases physician confidence in the diagnosis (from 7.1/10 after history to 8.2/10 after examination) and helps exclude alternative diagnoses 2.

Laboratory and Diagnostic Testing

• Order tests selectively based on history and physical examination findings rather than as routine screening 3, 4
• For diabetes patients specifically: obtain A1C, assess for complications with appropriate screening (retinal exam, renal function, cardiovascular assessment), and evaluate for comorbidities like thyroid disease in type 1 diabetes 1
• Avoid unnecessary testing that increases costs and exposes patients to risks without changing management 3

Laboratory investigation leads to diagnosis in only 11% of cases but increases diagnostic confidence to 9.3/10, primarily by confirming suspected diagnoses rather than revealing unexpected findings 2.

Patient Engagement and Communication

Establishing Collaborative Relationships

• Use neutral, non-judgmental language that is strength-based, respectful, and fosters hope 1
• Employ person-centered terminology (e.g., "person with diabetes" rather than "diabetic") 1
• Create a safe environment by sitting at the patient's level, maintaining appropriate eye contact, and ensuring privacy 5
• Begin with open-ended questions such as "What are the things you want to make sure we discuss today?" to give patients control over the agenda 5

Setting Goals and Expectations

• Engage patients in formulating the care management plan from the initial visit 1
• Establish individualized therapeutic goals through shared decision-making that considers the patient's values, preferences, and life circumstances 1
• Address patient understanding by asking "Tell me what you understand about why you're here" before providing information 5
• Use teach-back methods to confirm comprehension: "In your own words, what does this mean to you?" 5

Documentation Requirements

Essential Elements to Record

• Confirm or establish the diagnosis with appropriate classification 1
• Document baseline assessment of disease status, complications, and comorbidities 1
• Record the care plan including treatment goals, medication regimens, and follow-up intervals 1
• Note patient engagement in decision-making and their understanding of the plan 1

For telemedicine visits specifically, additional documentation includes patient consent, method of connection, patient and provider locations, and all participants present 1.

Establishing Ongoing Care

Follow-Up Planning

• Schedule follow-up visits at 1-2 month intervals initially, with frequency adjusted based on disease stability and patient mastery of self-management 1
• Plan for continuing care that includes monitoring of disease progression, treatment response, and development of complications 1
• Arrange appropriate referrals to specialists when indicated by examination findings or diagnostic results 1

Preventive Care Integration

• Provide age-appropriate vaccinations including annual influenza vaccine for all patients ≥6 months, pneumococcal vaccines per CDC schedules, and hepatitis B series for unvaccinated adults with diabetes 1
• Address cardiovascular risk by calculating 10-year atherosclerotic cardiovascular disease risk using Pooled Cohort Equations 1
• Screen for common comorbidities based on the primary diagnosis and patient risk factors 1

Common Pitfalls to Avoid

• Do not order routine laboratory panels without clinical indication from history and physical examination, as this increases costs without improving diagnostic accuracy 3, 4
• Avoid information overload by providing information in small doses and checking comprehension frequently 5
• Do not assume quiet patients lack concerns; directly ask "I'm wondering what you're thinking or if I'm missing something?" 5
• Resist providing solutions when patients are highly emotional, as they cannot process information effectively in that state; focus instead on empathic responses 5