Open the encounter and set expectations
Introduce your role, confirm how the person prefers to be addressed, and explain what will happen next. An opening reduces anxiety and makes later questions easier to understand.
Avoid beginning with rapid closed questions. Start broad, listen for the patient’s own words, then narrow the timeline and details. The vocabulary a patient uses may differ from textbook terminology.
Meu nome é Ana, sou fisioterapeuta. Primeiro vou ouvir o que aconteceu e depois faremos alguns testes, tudo bem?
My name is Ana, I am a physical therapist. First I will listen to what happened and then we will do some tests, okay?
Role, sequence, and consent to proceed.
Conte com suas palavras o que está incomodando mais hoje.
Tell me in your own words what is bothering you most today.
Invites the patient’s narrative.
Build the history from open to specific
After the opening narrative, clarify onset, location, character, intensity, pattern, triggers, associated symptoms, prior episodes, medications, allergies, and relevant history. Do not force every case through the same order if the patient reveals an urgent concern.
Repeat critical information and distinguish what the patient said from your interpretation. Dates, doses, allergies, and changes in symptoms deserve explicit confirmation.
- Quando começou?
- Onde exatamente você sente?
- O que melhora ou piora?
- Isso já aconteceu antes?
- Quais medicamentos você usa atualmente?
- Você tem alguma alergia conhecida?
Explain in layers and check understanding
Give the main point first, then the reason, then the next action. Replace unnecessary technical language with an everyday explanation; introduce the technical term only when it helps the person recognize a diagnosis, document, or referral.
“Entendeu?” often produces a polite yes. Teach-back is more reliable: ask the person to explain how they will take a medicine, monitor a symptom, or arrange follow-up. Frame it as a check on your explanation, not a test of the patient.
Quero ter certeza de que expliquei bem. Como você vai tomar este medicamento em casa?
I want to make sure I explained it well. How will you take this medication at home?
Places responsibility on the explanation.
O exame não mostrou uma emergência, mas precisamos acompanhar dois sinais específicos.
The test did not show an emergency, but we need to monitor two specific signs.
Separates reassurance from follow-up.
End with a safety net and documented next step
State what to do, when to do it, and what change requires faster action. Ask whether practical barriers could prevent the plan: cost, transport, schedule, literacy, support, or access to the service.
Practice written notes and patient-facing instructions separately. Clinical documentation may require a condensed professional register, while the patient needs direct language that can be followed at home.
- Next action and timing
- Warning signs
- Where to seek help
- Who will follow up
- How understanding was checked