This document outlines the sections and information to include in a Problem Oriented Medical Record (POMR). It details 10 sections to include: 1) chief complaint, 2) history of present illness, 3) past medical history, 4) medications and allergies, 5) family history, 6) personal history, 7) functional inquiry, and optional sections for 8) social history, 9) review of systems, and 10) physical exam. Each section provides guidance on the essential information to record, such as recording symptoms, medications, medical problems, and family illnesses.
This document outlines the sections and information to include in a Problem Oriented Medical Record (POMR). It details 10 sections to include: 1) chief complaint, 2) history of present illness, 3) past medical history, 4) medications and allergies, 5) family history, 6) personal history, 7) functional inquiry, and optional sections for 8) social history, 9) review of systems, and 10) physical exam. Each section provides guidance on the essential information to record, such as recording symptoms, medications, medical problems, and family illnesses.
This document outlines the sections and information to include in a Problem Oriented Medical Record (POMR). It details 10 sections to include: 1) chief complaint, 2) history of present illness, 3) past medical history, 4) medications and allergies, 5) family history, 6) personal history, 7) functional inquiry, and optional sections for 8) social history, 9) review of systems, and 10) physical exam. Each section provides guidance on the essential information to record, such as recording symptoms, medications, medical problems, and family illnesses.
CLINICAL SKILLS I PROBLEM ORIENTED MEDICAL RECORD 1 To Be Completed By Medical Studet! " Not #a$t O% O%%icial Medical Reco$d Date: ____________________ 1. Introductory Statement Introductory Statement is a brief one-sentence description introducing the patient to the reader. It may include the patient's age, sex, occupation, marital status, children, ethnicity, religion, living arrangement, and any other salient identifying characteristics. Name: _________________________________________________________________________ Medical Record No.: ___________________ Bed No.: __________________ Date o Admi!!ion: _______________________ A"e: _________________________________ Se#: ____________________________ $. Source! This is a statement of whether the history was obtained from the patient, relatives, or other sources (old medical records, ambulance driver, etc. and an expression of opinion concerning the reliability of the history obtained. !or example" #The reliability of the patient's history is uncertain having been obtained from his next-door neighbor $r. x% &nd the ambulance driver ...# Source o Inormation: _______________________________ Do you t%in& t%e !ource i! relia'le: Yes No not sure 1 *Original Source: Printed Matter From The Faculty Of Medicine merican !ni"ersity Of #eirut $ Mc%ill !ni"ersity &ase 'e(ort Format Name of Patient: Medical 'ecord No): #ed No): _______________________________ Name o Attendin" P%y!ician: Contacted( Yes * + No * + T%e )i!tory *. C%ie Com+laint This is the ma'or reason for which the patient comes to see a physician at a given time. It is expressed succinctly in a single sentence, often in the patient's own words, and includes the duration over which the complaint has lasted. &hief com(laint: ,. )i!tory o Pre!ent Illne!! This is the most important part of the history and, if properly obtained, the diagnosis of a patient's problem can be made from the history in approximately seventy percent of cases. (nfortunately, this is also the most difficult portion and the area where most omissions and errors in diagnosis are made. The )resent Illness refers to the recent change in a patient's health which caused him*her to see+ medical attention. It starts with the event or occasion which the patient notes as a change from his*her #usual# health (which may in fact be a low level of health and function and proceeds to the time of presentation for medical attention. The ,)I may begin as follows" #This -- year old male with longstanding ischemic heart disease and two previous $I's was in his usual state of health until - days prior to admission when ...#. !rom this point the )resent Illness is written in an orderly chronological manner including all symptoms, feelings and events that are pertinent to the patient's current illness. It is important to remember that the order in which the )resent Illness is written does not necessarily mirror the order in which the information was obtained. The description of the symptoms in the )resent Illness should be very specific and the following features of each symptom delineated" PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page - of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ Bodily loc!io"# T$e %i!e& or %i!e%& o' !$e com(li"! %$ould )e ide"!i'ied* C$ro"olo+y# T$e !ime o' o"%e!& !$e dur!io"& !$e (eriodici!y "d 're,ue"cy& "d !$e cour%e o' !$e %ym(!om% %$ould )e %(eci'ied* T$e 'i"l e-e"!.%/ 0$ic$ (rom(!ed !$e (!ie"! !o %ee1 medicl !!e"!io" %$ould )e %(eci'ied* 2uli!y# A de%cri(!io" o' !$e ,uli!y o' !$e %ym(!om& u%ully )e%! re(or!ed i" !$e (!ie"!3% o0" 0ord%& %$ould )e i"cluded* 2u"!i!y# T$e -olume& i"!e"%i!y& %i4e& "um)er or "y o!$er ((ro(ri!e ,u"!i'ic!io" o' !$e (!ie"!3% %ym(!om %$ould )e recorded * * * Se!!i"+# T$i% i% de%cri(!io" o'# 1* $o0 !$e (!ie"!5% li'e circum%!"ce% $-e ''ec!ed !$e de-elo(me"! o' %ym(!om%& "d 2* $o0 !$e %ym(!om% $-e ''ec!ed !$e (!ie"!3% li'e%!yle* A++r-!i"+ or lle-i!i"+ 'c!or%# T$e u!ili4!io" "d e''ec! o' dru+%& c$"+e% i" (o%i!io"& re%!& e!c*& o" !$e %ym(!om %$ould )e de%cri)ed* A%%oci!ed m"i'e%!!io"%# T$i% i"clude% 'ull e",uiry o' !$e or+" %y%!em.%/ !$ou+$! !o )e i"-ol-ed % 0ell % re-ie0 o' co"%!i!u!io"l %ym(!om%* The ,istory of )resent Illness ends with the hospital admission. It should be clearly stated why the patient sought medical advice at the particular time when he/she came to see a physician. PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page / of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ The concluding paragraph of the present illness should contain pertinent positive and negative information to answer any anticipated .uestions regarding the patient's differential diagnosis. This typically includes a functional en.uiry of the system thought to be involved in the patient's illness. It should also include comments on general well- being, changes in weight or color, changes in lifestyle, and functional capacity secondary to the illness, recent medications and any other information deemed important to the present illness (i.e. family history in the case of genetic disease. Present lllness: PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 0 of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________
-. Pa!t Medical )i!tory The )ast $edical ,istory is a record of all previous illnesses including medical and psychiatric illnesses, surgical procedures and an obstetrical history if appropriate. These are all listed chronologically beginning with the most remote and proceeding to the most recent. They should include the date, the hospital (if an admission was re.uired, the diagnosis, the treatment, the complications and the se.uelae. Medical +ro'lem! Sur"ical +rocedure! O'!tetrical %i!tory i a++ro+riate P!yc%iatric illne!!e!
1os(itali2ations 3ate 4ocation 'eason
________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ccidents5 trauma: 6mmuni2ations PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 7 of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ -. Medication! and Aller"ie! com(lete list of all medications ta8en (re,hos(itali2ation as 9ell as 8no9n drug5 food and other allergies should :e listed) &urrent; (ast medications: 3rug 3ose 3uration 3rug 3ose 3uration Of inta8e of inta8e 1) <) -) =) /) >) 0) .) 7) 1?) llergies: drug5 food5 other) .. /amily )i!tory This provides data concerning hereditary disease and familial illness. It should contain information about all the patient's blood relatives, the illnesses they have, and if they are dead, their age at death, and the illnesses they had at the time of death. & convenient format for this is as follows" Family history: consanguinity5 dia:etes5 thyroid disease5 hy(erli(idemias5 malignancies *s(ecify ty(e and location+5 renal disease5 allergies5 hy(ertension5 heart disease5 neurologic disease5 (sychiatric disease5 musculos8eletal5 sic8le cell5 thalassemia5 :leeding tendency5 %6 disease PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page < of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ 0. Per!onal )i!tory This section provides a profile of the patient as a person including" Erly 6e-elo(me"!# Plce o' )ir!$& c$ild$ood de-elo(me"!& $el!$ c!i-i!ie%& %ocil "d eco"omic e"-iro"me"! Educ!io"# Sc$ool $i%!ory& -oc!io"l !ri"i"+ Socil Ac!i-i!ie%# Recre!io"%& reli+iou% "d commu"i!y %u((or! +rou(% 7or1 Record# A+e )e+u"& !y(e& "um)er o' 8o)%& %ucce%% "d 'ilure& i"du%!ril $4rd% "d e9(o%ure%& (re%e"! 0or1 H)i!%# Li-i"+ co"di!io"%& die!& lco$ol& dru+%& !o)cco :ri!l S!!u%# ;mily %!ruc!ure& curre"! li-i"+ rr"+eme"!% e!c* Patient (rofile: #irth (lace___________________ @ducation _______________ Marital status_______________ Occu(ation______________________ @n"ironmental eA(osure_____________________ &ountries "isited recently__________________________ Food intolerance and food fads_______________________ dditional historical data dditional &omments PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page = of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ 1. /unctional En2uiry The functional en.uiry is an integral part of the case report. It is designed to give an overview of those systems not covered in the )resent Illness. In recording the functional en.uiry in the case report it is unnecessary to repeat those portions previously recorded in the Present Illness or Past Medical History. /ot all this information is desirable in case reports although at the beginning of one's clinical training it is appropriate to practice using these .uestions in a systematic way so as to gain necessary experience with them. $any of the following symptoms are formal medical terminology and need to be communicated in layman's language to your patients. Instructions: Circle positive or abnormal responses and comment appropriately. Underline negative or normal responses. Leave unaltered if information not available. Sy!tem! Re3ie4: 1+ %eneral: Bea8ness5 Fatigue5 a((etite5 change in 9t) _________________5 slee(ing ha:its5 chills5 fe"er5 night s9eats -+ 6ntegument: &olor changes5 (ruritus5 infections5 tumor *:enign ;malignant+5 hair changes nail changes5 s8in disease5 change in moles5 rash5 alo(ecia5 (igmentation) /+ @yes "ision5 date of last eAamination5 ____________________ scotomata5 (ain5 di(lo(ia5 (hoto(ho:ia5 glaucoma5 refraction errors) 0+ @ars: tinnitus5 hearing loss5 discharge5 other) 7+ Nose5 throat and sinuses: e(istaAis5 discharge5 sinusitis5 hoarseness5 recurrent sore throat) PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page > of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ <+ &entral Ner"ous: headache5 di22iness5 synco(e5 sei2ures5 "ertigo5 di(lo(ia5 (aralysis ; (aresis5 tremor5 muscle 9ea8ness5 ataAia5 sensory a:normalities5 head trauma5 history of meningitis5 other) =+ #reasts: Masses5 discharge5 (ain >+ @ndocrine: %oiter5 heat intolerance5 cold intolerance5 family history of dia:etes5 (olyuria5 (olydi(sia5 (oly(hagia5 inta8e of hormones .+ 1ematological: nemia5 a:normal :leeding5 :ruising5 adeno(athy5 family history of hematologic disease5 other) 1?+ &ardio"ascular: &hest (ain5 ty(ical angina (ectoris5 dys(nea on eAertion5 ortho(nea5 (aroAysmal nocturnal dys(nea5 (eri(heral edema5 murmur5 (al(itations5 "aricosities5 throm:o(hle:itis5 claudication5 'aynaudCs (henomenon5 synco(e5 near synco(e5 (ast heart disease5 rheumatic fe"er5 hy(ertension5 inta8e of cardio"ascular drugs5 other) 11+ Pulmonary: &ough *(roducti"e ; non (roducti"e+5 change in cough5 amount and characteristics of s(utum (roduction5 ______________________5 (ac8 years of to:acco usage ________________9hee2ing5 hemo(tysis5 recurrent res(iratory tract infections5 (ositi"e tu:erculin test5 shortness of :reath5 (re"ious chest radiogra(h5 family history of chest disease) 1-+ %astrointestinal: 3ys(hagia5 indigestion5 heart:urn5 nausea5 "omiting5 diarrhea5 consti(ation5 melena5 hematemesis5 rectal :leeding5 change in :o9el ha:its5 a:dominal (ain5 a:dominal s9elling5 Daundice5 dar8 urine5 clay colored stools5 food intolerances5 eAcessi"e gas5 use of antacids5 use of laAati"es5 hernia5 hemorrhoids5 (arasites5 (e(tic ulcer disease5 gall :ladder disease5 PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page . of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ (ancreatitis5 gastrointestinal surgery5 alcohol inta8e5 family history of %l malignancy5 other) 1/+ !rinary tract: Nocturia5 freEuency5 urgency5 dysuria5 hematuria5 difficulty in starting urinary stream5 urinary stream a:normalities5 incontinence5 (olyuria5 renal calculi5 infections5 flan8 (ain5 (re"ious urine eAamination5 (re"ious radiogra(hy of urinary tract5 family history of renal disease5 other)
PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1? of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ 10+ %enitore (roducti"e system: a+ Male: Penile discharge5 lesion5 history of "enereal disease5 serology5 testicular mass5 infertility5 im(otence5 li:ido5 history of undescended testicules) :+ Female: %ynecologic history: age of menarche________________5 last menstrual (eriod______________5 age at meno(ause_____________5 (ost meno(ausal :leeding5 a:normal menses5 amount of :leeding5 intermenstrual :leeding5 (ostcoital :leeding5 leucorrhea5 (ruritis5 history of "enereal disease5 serology5 last PPs____________5 results__________5 (el"ic (ain5 (el"ic mass5 other) c+ O:stetric history: Full term deli"eries_______________5 (regnancies_____________ a:ortions_____________5 li"ing children_______________ com(lications of (regnancies5 infertility5 li:ido) d+ Methods of contrace(tion: 17+ Musculos8eletal system: a+ Foints: (ain5 s9elling5 heat5 redness5 stiffness5 deformity5 family history of Doint disease) :+ Myalgias5 family history of muscle disease 1<+ Psychiatric: 1y(er"entilation5 ner"ousness5 de(ression5 insomnia5 nightmares5 memory loss5 drug a:use) ny suggestion of (sychotic sym(tomsG Yes_______No_______ PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 11 of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ 5. P%y!ical E#amination The art of medicine includes a thorough history and a thoughtful physical examination followed by the interpretation of this data. Information recorded in the physical examination section should be the findings made during the patient's exam and not the interpretation of these observations. This is at times difficult to do and re.uires practice to fully master. The following outline will serve as a guide in performing and recording a physical examination. P%y!ical E#amination Hital signs: Pulse reg; irreg) 'es(irations_____________Tem(______________oral ; rectal #lood (ressure: Su(ine ' arm__________________su(ine 4 arm______________4eg_____________ Standing ' arm________________standing 4 arm_____________________________ Beight______________________1eight________________________ %eneral: 6ntegument: Turgor5 teAture5 (igmentation5 cyanosis5 telangiectasia5 (etechiae5 (ur(ura5 ecchymosis5 infection5 lesions5 hair5 nails5 mucous mem:ranes) 4ym(h nodes: &er"ical5 (ostauricular5 su(racla"icular5 aAillary5 inguinal5 other) S8ull: Trauma5 :ruits5 other @yes: 4acrymal glands5 cornea5 lids5 sclerae5 conDuncti"ae5 eAo(htalmus5 lid,lag PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1- of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ Fundi: 3iscs5 arteries5 "eins5 hemorrhages5 eAsudates5 microaneurysms @ars: To(hi5 tym(anic mem:ranes5 eAternal canal5 hearing5 air conduction5 :one conduction5 laterali2ation PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1/ of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ Mouth5 nose and throat: 3entition5 gingi"al tongue5 tonsils5 (harynA5 nasal mucosa5 nasal se(tum5 sinuses Nec8: Mo:ility5 scars5 masses5 thyroid5 sali"ary glands5 tracheal shift5 :ruits #reasts: Masses5 discharge5 ni((les5 asymmetry5 gynecomastia5 s8in &hest: 'es(iratory rate ___________ ;min) m(litude: shallo95 dee(5 normal 'es(iratory rhythm: regular5 irregular5 (eriodic5 (rolonged eA(iration &hest 9all: 3eformities5 eAcursion: good5 fair5 a:sent5 use of accessory muscles uscultation: Bhee2es5 rhonchi5 crac8les5 ru:s5 :reath sounds: increased5 decreased5 normal5 other *3iagram location of a:normal :reath sounds5 transmitted "oice5 or a:normal (ercussion+ PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 10 of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ &ardio"ascular system: , @Aternal Dugular "eins distended ; Not distended , 1e(atoDugular refluA , &arotid: thrill5 :ruit5 u(stro8e_______________ , Precordium: acti"e5 Euiet Point of maAimum im(ulse: ____________________ 1ea"e *4H;'H+5 thrill *Systolic; diastolic+5 location: Pal(a:le ecto(ic (ulsation S1: S-: S/: *heard5 not heard+ S0: *heard5 not heard+ %allo(s: &lic8s: other: Systolic murmurs grade5 location5 radiation: 3iastolic murmurs grade5 location5 radiation: 3iastolic murmurs and grades: Other: 3iagram &lu::ing5 cyanosis5 edema5 throm:o(hle:itis5 (aradoAical (ulse5 stasis5 ulceration &arotid #rachial 'adial orta Femoral Po(liteal PT 3P _'__6_________6_________6_________6________6_________6________6_____6______6 _4 __6_________6_________6_________6________6_________6________6_____6______6 Scales ?,0 @Aaggerated / ) Normal 0) 3iminished -) Fust (al(a:le) :sent ?) PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 17 of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ :domen: O:esity5 contour5 scars5 "enous collaterals5 hernias5 (ulsations5 tenderness5 &H tenderness5 masses5 re:ound5 rigidity5 fluid 9a"e5 shifting dullness5 fran8 ascites5 :ruits) #o9el sounds: Normal5 a:sent5 hy(eracti"e5 hy(oacti"e Organomegaly: 4i"er5 s(leen5 8idneys5 :ladder5 gall :ladder5 *descri:e fully (ositi"e findings use diagram if necessary+ Male: %enitalia: (enis5 scrotum5 testes5 e(ididymis5 masses5 other) 'ectal: (erineum5 hemorroids5 s(hincter tone5 (rostate5 masses5 :leeding5 stool Female: @Aternal genitalia5 la:ia5 clitoris5 introitus5 urethra5 (erineum5 other 6nternal genitalia: "agina5 cer"iA5 adneAa5 cul,de,sac5 discharge Pa(s: done5 omitted 'ectal: hemorroids5 s(hincter tone5 :leeding5 masses5 stool Foints: 'ange of motion: fingers5 9rist5 el:o95 shoulder5 hi(5 8nee5 an8le 3eformity5 redness5 heat5 edema5 tenderness) S(ine: deformity *8y(hosis5 lordosis5 scoliosis+5 range of motion5 muscle s(asm5 tenderness5 others) Neurological: ((earance5 affect5 motor :eha"ior5 memory5 general attention s(an5 Dudgment5 a:straction5 delusions5 hallucinations5 mental state5 orientation to time5 (erson5 and (lace 4e"el of consciousness: alert 9a8efulness5 lethargic5 o:tunded5 stu(orous5 semi, comatose5 comatose) 4aterali2ing cortical functions: s(eech and other dominant hemis(here functions5 non dominant hemis(here functions5 handedness ' ; 4 PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1< of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ &ranial ner"es: 6: Not tested5 tested *list test materials+ 66: 3iscs5 (a(illedema5 "enous (ulses5 o(tic atro(hy5 "isual fields5 acuity) 6665 6H5 H6: Ptosis5 (al(e:ral fissure Pu(ils: eEual5 uneEual5 dilated5 constricted5 normal) 'eaction to light: ' 4 &onsensual reaction: ' to 4 4 to ' 'eaction to near "ision: ' 4 @Atra ocular mo"ements: dolls,eyes5 cold calories5 ga"e (reference5 nystagmus5 others) H: Sensory: 1 st di"ision - nd di"ision / rd di"ision ' corneal 4 corneal Motor: masseters5 (terygoids5 tem(oralis H66: 6ntact ' ; 4 central ' ; 4 (eri(heral H666: 6ntact 6I5 I: 3ysarthria5 gag5 (honation5 u"ula5 soft,(alate5 s9allo9ing I6: Sternocleidomastoids5 tra(e2ii I66: Tongue in midline5 de"iation to ' ; 45 atro(hy5 fasiculations5 ra(id alternating Mo"ements %ait and station *not tested+: Bal8ing: normal5 a:normal5 heel 9al8ing5 toe 9al8ing5 tandem 9al8ing Truncal ataAia 'om:erg: ' ; 4 6n"oluntary mo"ements PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1= of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ &ere:ellum: 'a(id alternating mo"ements5 finger,nose5 heel,shin5 (ast,(ointing5 (osturing Sensory: Pain5 tem(erature5 light touch5 Doint (osition5 "i:ratory t9o (oint discrimination5 Stereogenesis ssociati"e functions: S(eech5 9riting5 reading5 a(raAia5 agnosia5 other Motor: Tone5 mass5 fasciculations5 tremor5 hemi(aresis5 hemi(legia 'efleAes: #i Tri #r J Plantar :domen ? K a:sent5 tr K trace5 1L decreased5 - L K normal5 / L K hy(eracti"e5 0L K sustained clonus 16. Summary The Summary is a brief recapitulation of the pertinent symptoms and signs elicited during the patient interview and physical examination. It is fre.uently divided into two parts" 0. Sub'ective - The significant historical findings (i.e. ,)I, )ast $edical ,istory, )ersonal and !amily ,istory. 1. 2b'ective - The significant positive physical findings. (& 3ab 4ata section usually follows the )hysical 5xamination and the pertinent lab results are then summari6ed here. It should be remembered that the role of the Summary is chiefly as a teaching tool to help clarify what portions of the history, physical examination and laboratory results are important for formulation of a problem list and diagnostic impression. PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1> of 1. Name of Patient: Medical 'ecord No): #ed No): _______________________________ ________________________ Student Signatures indicate agreement 9ith 3ata #ase content) @Ace(tions and additions should :e noted and dated) __________________________________________ 'esident ; ttending Physician PHYSICIAN PATIENT RELATIONSHIP CLINICAL SKILLS I Summer 2014 POM' , Page 1. of 1.