At besa Health, every patient encounter is an opportunity to deliver care that is thorough, compassionate, and clinically sound. This guide outlines the step-by-step structure every provider is expected to follow to ensure a consistent, high-quality standard of care. Remember, the way the encounter goes and how the Patient feels is determined by the micro expressions or steps that you make throughout the encounter process. 

⚠️ If for any reason you are not able to access the EHR and the Patient is there at the facility, please use the Backup paper copy of the encounter form. We will then input it into the EHR when available. 

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📋 1. Preparation (Before the Encounter)

  • Review Patient Information in Advance
    • Chief Complaint: Understand the patient’s primary concern.
    • Medical History: Review chronic conditions, surgical history, family history.
    • Medication List & Allergies: Identify interactions or contraindications.
    • Recent Visits or Tests: Note recent labs, imaging, referrals, or previous care plans.
    • Social/Behavioral Health: Acknowledge context such as housing, stressors, language needs, and support systems.
  • Mental Preparation
    • Approach the encounter with a clear mind, clinical curiosity, and empathy.
    • Remind yourself: You are here to listen, guide, and make sound medical decisions.

 

🤝 2. Greeting & Establishing Connection

  • How to Begin
    • Confirm the Patient you’re with matches the Patient on record.
    • Smile when calling them in (in-person) or smile and wave (virtual).
    • Greet the patient warmly by name and introduce yourself.
    • Sit at eye level and make eye contact.

Tip: “Hi [Patient’s Name], it’s great to see you. How have you been since our last visit?” “Thanks for taking the time to be here today.”

 

  • Build Trust
    • Maintain open body language.
    • Actively listen before speaking.
    • Use verbal and non-verbal affirmations (e.g., “I see,” nodding)
    • Touch when it deems appropriate.
    • Tell a funny story, or tell them something they may relate to, or you relate to regarding when they said.

Tip: “I know medical visits can feel rushed—my goal is to really understand what’s going on with you today.”

 

🗣️ 3. History Taking (Subjective Assessment)

  • Chief Complaint & History of Present Illness (HPI)
    • Use open-ended questions to let the patient explain their concern in their own words.

      Tip: (1) “Tell me what brought you in today.” (2) “What’s been bothering you the most lately?”
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    • Then use the OLDCARTS or OPQRST framework to structure your follow-up:
    • Onset
    • Location
    • Duration
    • Character
    • Aggravating/Alleviating factors
    • Radiation
    • Timing
    • Severity
  • Past Medical, Surgical, Family, and Social History
    • Update existing history and explore new risk factors.

      Tip: (1) “Do you have any long-term conditions like diabetes, heart disease, or asthma?” (2) “Any surgeries or hospital stays I should know about?” (3) “Are there any conditions that run in your family?” (4) “Tell me about your living situation—do you feel safe and supported?” (5) “What do you do for work?” (6) “Do you use tobacco, alcohol, or any recreational substances?”

      If the patient is vague: (1) “Can you walk me through a typical day when this happens?” (2) “What do you mean when you say it ‘comes and goes’?”
  • Medication Reconciliation
    • Confirm medication name, dose, frequency, adherence, and side effects.
  • Review of Systems (ROS)
    • Perform a focused ROS based on the chief complaint.

 

🔍 4. Physical Exam (Objective Assessment)

  • Conduct a Targeted, Focused Exam
    • Based on HPI, perform a focused or full systems exam as clinically indicated.
    • Document findings thoroughly and objectively (positive and negative).
    • Observe physical appearance, vitals, and patient demeanor.

      Tip: (1) “I’m just going to check your heart and lungs—let me know if anything feels uncomfortable.” (2) “Let me take a quick look at your joints—tell me if there’s any tenderness.”
      Respecting Boundaries: (1) “Is it okay if I touch here?” (2) “I want to make sure we’re thorough while keeping you comfortable.”

 

🧠 5. Assessment: Clinical Thinking & Differential Diagnosis

  • Build a Differential Diagnosis
    • Begin formulating 2–5 possible causes for the presenting symptoms.
    • Organize differentials by most likely, most dangerous, and must-not-miss.
    • Include zebras if symptoms are atypical or unexplained.
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  • Use Evidence-Based Frameworks
    • Reference clinical guidelines (e.g., besa Health, CDC, USPSTF, AAFP, UpToDate, etc.).
    • Apply decision tools (e.g., Centor criteria, Wells Score, Ottawa Rules) when appropriate.
    • Consider red flags and atypical presentations based on age, gender, or comorbidities.

      Tip: Talk through your thought process with the Patient - (1) “Here are a few possibilities I’m considering based on what you’ve told me.” (2) “I’m not jumping to conclusions—I want to order the right tests to confirm what’s going on.”

 

📈 6. Plan: Diagnostics & Treatment

  • Order Appropriate Tests
    • Labs, imaging, screenings, or specialist referrals as indicated by your differentials.
    • Always communicate why a test is being ordered.
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  • Prescribe Judiciously
    • Choose first-line evidence-based treatments.
    • Consider cost, availability, adherence, and potential side effects.
    • Explain to the patient how and when to use medications, and what to monitor.
  • Care Plan & Follow-Up
    • Set clear, achievable goals with the patient.
    • Assign follow-up intervals and explain when to return or escalate care.
    • Use SMART goals: Specific, Measurable, Achievable, Relevant, Timely.

      Tip: Clearly explain why this is your plan, why these things have been ordered, and ask them how they feel, etc - (1) “We’re ordering this blood test to check if there’s inflammation that might explain your symptoms.” (2) “This medication can help reduce your symptoms quickly—but let’s monitor for side effects.” (3) “Here are a couple of options—let’s talk about what works best for your lifestyle.” (4) “How do you feel about that plan?”
      Set the expectation for the future: (1) “If things don’t improve in 2–3 days, I want you to check back in with me.” (2) “Here’s exactly what I’d like you to do before our next visit.”

 

👥 7. Education & Shared Decision-Making

  • Explain Clearly & Respectfully
    • Translate clinical terms into patient-friendly language.
    • Use teach-back: Ask the patient to repeat key elements to ensure understanding.
  • Involve the Patient
    • Discuss options and let the patient participate in the care decision.
    • Respect cultural, religious, or personal preferences in treatment approaches.

      Tip: (1) “Your blood pressure is a little high. I’d like to help you bring that down to protect your heart.” (2) “Can you tell me in your own words what our plan is today?” (3) “What questions do you have before we wrap up?” (4) “Was there anything you were hoping to talk about that we didn’t cover yet?”

 

🧾 8. Documentation

  • Chart Accurately & Thoroughly
    • Ensure all key components of the SOAP (Subjective, Objective, Assessment, Plan) note are complete.
    • Use AI scribing tools where available, but review thoroughly for accuracy.
    • Include time spent, informed consent, education provided, and coordination of care.

 

🔄 9. After the Visit

  • Coordinate & Communicate
    • Ensure orders are sent, referrals made, and instructions relayed to support staff.
    • Close the loop with the team, and care coordinators as needed.
    • If an order needs to be made be sure to add their desired days and times in the notes so it can be scheduled accordingly. We want to try to remove steps for the Patient.
  • Maintain HIPAA Compliance
    • All documentation and communication must meet privacy standards.

 

At besa Health, our patients deserve clinical excellence wrapped in compassion. That means being fully prepared, thinking critically, using evidence, and always remembering that every chart is a person.

Great providers don’t just treat symptoms—they treat Patients.