Sunday, September 7, 2008

Practice

The practice of medicine combines both science as the evidence base and art in the application of this medical knowledge in combination with intuition and clinical judgment to determine the treatment plan for each patient.

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.

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