Essential Components of Primary Care

Patient Assessment and History-Taking

The American Academy of Family Physicians recommends using open-ended questions to assess patient concerns and priorities, such as "What do you like about using [substance]?" rather than confrontational approaches 4
The American Heart Association suggests that for hypertension and diabetes cases, a "know your numbers" assessment should include BMI, blood pressure, A1C, lipid panel, eGFR, and UACR 1, 2, 3
The Centers for Disease Control and Prevention recommends assessing lifestyle factors, including tobacco use, alcohol consumption, diet, exercise, and sleep patterns, as the single most important modifiable risk factor 1, 2, 3
The American College of Physicians suggests that social determinants of health, such as employment, housing stability, food security, and health literacy, should be assessed in patients with hypertension and diabetes 1, 2

The American College of Cardiology recommends testing recognition of critical findings, including vital signs interpretation, body habitus assessment, and cardiovascular examination 1, 6, 2
The Infectious Diseases Society of America suggests that HIV and sexual health history should include questions on sexual practices, exposure sites, partner HIV status, and injection drug use practices 5, 6
The American Diabetes Association recommends that diabetes screening should include A1C, fasting plasma glucose, and time in range, with a target A1C <7% 1, 2, 3

The American Heart Association suggests that hypertension management should include lifestyle modifications, such as weight reduction, DASH diet, sodium restriction, physical activity, and alcohol moderation, as well as medication selection and avoidance of therapeutic inertia 9
The American Diabetes Association recommends that diabetes management should include comprehensive education, self-monitoring blood glucose, dietary counseling, and target A1C <7% 9
The Substance Abuse and Mental Health Services Administration suggests that substance use treatment should include motivational interviewing techniques, benzodiazepine tapering, and referral indications 4

The American Academy of Family Physicians recommends that patient education should include eliciting patient priorities, providing education at every visit, using plain language, and encouraging patient belief in their ability to control health outcomes 1, 2
The National Institute on Aging suggests that health literacy considerations should include tailoring to individual patient needs, accounting for social determinants, and repeating and reinforcing key concepts 1, 2

The American College of Physicians suggests that clinical reasoning errors, such as therapeutic inertia, inadequate follow-up intervals, overlooking medication adherence, and neglecting lifestyle modifications, should be identified and addressed 9
The American Medical Association recommends that documentation errors, such as excessive template use, cloned documentation, and inaccurate macro-generated findings, should be recognized and avoided 7