Central to medicine is the patient-physician relationship established when a person with a health concern seeks a physician's help; the 'medical encounter'. Other health professionals similarly establish a relationship with a patient and may perform various interventions, e.g. nurses, radiographers and therapists.
As part of the medical encounter, the healthcare provider needs to:
- develop a relationship with the patient
- gather data (medical history, systems inquiry, and physical examination, combined with laboratory or imaging studies (investigations))
- analyze and synthesize that data (assessment and/or differential diagnoses), and then:
- develop a treatment plan (further testing, therapy, watchful observation, referral and follow-up)
- treat the patient accordingly
- assess the progress of treatment and alter the plan as necessary (management).
The medical encounter is documented in a medical record, which is a legal document in many jurisdictions.
