Clinical interview guide aimed at primary care: a three-dimensional approach

Introduction: Teaching skills for interviewers to effectively integrate and conduct a medical consultation is essential in medical education. However, early-year medical students face challenges in producing high-quality clinical records without proper guidance. Thus, an interview guideline was developed to collect information during medical consultations and improve care. This guideline is based on the patient-centered clinical method, seven-step framework for consultation, and problem-oriented medical record to standardize documentation and integrate patients into the electronic health record. Experience report: An extensive literature review was conducted using PubMed, SciELO, and Virtual Health Library databases with the descriptors “clinical record”, “medical education”, “anamnesis”, and “family health history.” Also, specialized books were used for the theoretical framework. The initial interview guideline was reviewed by experts in medical education and clinical practice and discussed with undergraduate students. Discussion: The interview guideline combined three distinct and complementary methodological approaches, expanding the learning scope and systematizing the medical consultation into defined stages. The guideline initially describes Preparation and First minutes steps, focused on organization and welcoming the patient. In the Subjective step, the demand and relevant topics for a comprehensive understanding of the patient are explored, including sociocultural context, previous and family medical history, and health promotion and disease prevention. In the Objective step, the interviewer records the observed data, including physical and complementary test results. The Assessment step involves defining a list of problems to develop diagnostic, therapeutic, follow-up, and health education plans, which are recorded in the Plan. Finally, any remaining questions are addressed, and final instructions are provided. After the consultation, a moment for self-reflection and mental rest is suggested for the interviewer. Conclusion: The use of this interview guideline aims to enhance the communication skills of interviewers for effective data collection, supporting students in managing the consultation. Also, this guideline may be a tool for humanizing and strengthening patient-professional relationships.