Exam Pass Notes

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Purpose of Questions

• Questions at first contact help the practice follow the correct process and make accurate records.
• They are not for diagnosing, reassuring clinically, judging seriousness or deciding that a clinician is unnecessary.
• Tell patients why you are asking: the aim is safe routing and accurate records, not gatekeeping.
• Ask only the information required by your local script, template or escalation process.

Question Technique

• Open questions let the patient describe the request in their own words.
• Closed questions gather discrete facts needed by a protocol or template.
• Clarifying questions check what the patient means without suggesting an answer.
• Neutral wording avoids assuming urgency, cause, seriousness or priority.

Privacy, Refusal and Sensitive Details

• Offer privacy when possible, especially at the desk or if a sensitive issue arises.
• Request the minimum useful information rather than a full clinical history.
• If a patient refuses to answer, explain briefly why the information matters and offer a safer way to share it.
• Escalate if refusal, distress, safe-contact concerns or privacy barriers prevent safe routing.

Boundaries and Records

• Do not provide diagnoses, medication advice, false reassurance or clinical interpretation.
• When asked for advice, explain the practice route and what will happen next.
• Record the patient’s own words where possible and separate their account from staff interpretation.
• Document access needs, refusal, escalation, handover and who is responsible for the next action.