Patient Assessment and Information Gathering
Domain 2: Patient Assessment and Information Gathering
This domain tests the mechanics of a thorough, efficient history: how to open, funnel, screen, and close while keeping the patient's agenda in view.
Core rules
- Start broad ("What would you like to discuss today?") and let the patient finish. Then funnel: open questions, then focused, then closed and direct.
- Elicit ICE early: Ideas (what do you think is causing this?), Concerns (what worries you most?), Expectations (what were you hoping we could do?).
- Use a structured symptom framework such as SOCRATES for pain (Site, Onset, Character, Radiation, Associations, Timing, Exacerbating/relieving factors, Severity) or OLDCARTS.
- Ask one question at a time; compound questions get answered only in part.
- Avoid leading questions ("you haven't had any bleeding, have you?"), which inflate false positives.
- Announce sensitive topics and seek permission: "I ask everyone about mood and safety - is that all right?"
- Summarise periodically and chunk-and-check: short summary, then "did I get that right? What have I missed?"
- Close with "What else?", a clear plan, and safety-netting advice.
Worked example
A 55-year-old reports chest tightness. Instead of listing cardiac risk factors immediately, open with "Tell me about the tightness", work through SOCRATES, then ask ICE: "What do you think is going on?" He fears a heart attack because his father died at 56. That concern, not the pain score alone, drives the next step. Summarise, check the summary, then explain the plan.
Traps
- Interrupting the opening statement and losing the presenting concern.
- Accepting "no" to "any other problems?" as a complete screen.
- Anchoring on the first hypothesis and ignoring the patient's own explanation.
- Skipping psychosocial and safety screening because the physical history "ran out of time".