When a patient presents to the office for care, they typically have a specific complaint in mind – lower back pain, whiplash, sinus congestion, sciatica, etc.They are often not interested or engaged in what they consider "unrelated" personal health history – however the standard of care dictates that we cover those bases. In my practice, I have a mental checklist I run through for a basic health history and review of symptoms. This often rounds out my clinical understanding of the patient's health background, and it usually covers most of the meaningful use information we are now required to document.
To get the information and background you need, don't be afraid to ask different questions. This only helps you be more complete in your documentation. It doesn't have to take a lot of time, but it does require some conscious engagement on the part of the interviewer. A good example would be blood pressure. During the interview, I will often ask the patient if they have any issues with circulation or blood pressure – the common response is "No" – but if you follow up and ask about medications they will list five different prescriptions for blood pressure and cholesterol. Quite often the patient will assume that since they are on the medications and everything is "normal" they are fine and there is no problem. Not all patients are intentionally deceitful – some just don't make the connection – but make sure to cover the bases. You have to look beyond the direct answer and tie all the information together to come up with a complete clinical picture.
Another common background note is surgery. Many patients state they have no surgical history, but then when you ask about their eyes they will tell you their vision is great since they had Lasik last year or maybe they have had some gut problems since they had their gallbladder out. Many times patients just forget that they had a surgery until you remind them. I have had patients deny surgery but if you ask about the scar at the navel, they will respond "Oh, that's from my laparoscopy last year." Often they consider it a "minor procedure" instead of a legitimate surgery. We all know scar tissue is a major obstruction to the normal flow of qi. Wisdom teeth, cholecystectomy, hernia repair, arthroscopy, tubes in the ears – these are all legitimate surgeries that should be noted in the history.
With the impending change to ICD-10, and the new standard of care for documentation it is critical that you take the time to get a complete and accurate history. Having a good understanding of the history – previous injuries, medications, allergies to medications, family history and previous types of treatment are all relevant information. Some patients may even be a little surprised when you ask about other aspects of their healthcare.
I have had a few patients that did not feel that I had any business knowing about more than just the spine – but as physician providers it is our responsibility to review and document the scope of the history. This can become more significant when dealing with an injury claim – knowing if there was a similar injury in the past and documenting that up front can save you a lot of headache down the road.
The case history doesn't always stop with the interview either. As you physically evaluate the patient you may have findings – bumps, scars, etc – that warrant further questions. I noted above about a patient with a laparoscopic scar, who denied surgery. You may have a patient that denies cardiovascular issues, but has pitting edema and stasis dermatitis in the legs. On palpation you may find a lipoma on the back the patient did not even know about. Any of these findings would warrant questions to fully round out your case history notes. Don't be afraid to talk to patients. They came to you for care – most people like to talk about themselves, so if you ask good questions you can get them to give you a lot of information about their condition. If you can take a good history, you should have a clear idea of what the condition and diagnosis is before you start your exam – at that point your exam is just to confirm your clinical impression and specify the findings.
I know some doctors that have their staff "do the note stuff" and then they just come in and deliver the treatment – that is sad. I am sure that some people find taking the time to interview a patient time consuming drudgery – but it is part establishing a working relationship with the patient. Doing and interview and covering all bases – case history, health history, review of systems, medications, allergies, etc. – does take time, but it will only serve to make your documentation and case management better. I shared several times in the past we must think outside the acupuncture bubble and in terms of healthcare in general. Ultimately it is the patient that we take care of - not the insurance companies, attorneys or other providers. Whether or not you feel obligated to document all aspects of a case - responsible patient care mandates it. Acupuncture deserves every bit of respect that any other health profession does, but that respect comes with a level of responsibility. Yes, it is a pain; yes, it takes more time – but like it or not, thorough and complete documentation paperwork is part of professional healthcare.
- Dale Carnegie – How to Win Friends and Influence People
- Dr. Phil Paone – my good friend, mentor, and orthopedic exam instructor at Palmer College
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.