Academy of Chiropractic’s
Lawyers PI Program
Office Systems #18
From the Desk of:
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
"Reduce Examination Time"
One of the biggest limiting factors in our offices is the history component of the examination. Many doctors historically take 20-30 minutes during this part of the encounter (excluding the physical examination part) in order to gather all pertinent information and to ensure that compliance is met concurrently. In doing to, this process often backs up patient care and both the patients waiting and the staff gets frustrated. As a caring and thorough doctor, you refuse to cut corners.
However, the question begs itself "do those doctors who spend less time do a poor, or incomplete job in their history"? My answer as a rule is an emphatic "NO"! Here are a few significant "tips" that can help you become more efficient in the time you spend with patients. Remember, the patient in front of you, often wants out as quickly as possible as well. People do not want their lives' to revolve around our offices.
The 2 biggest "time wasters" are having the patient explain their pain to you and secondly, you explaining your services to them during the new patient evaluation.
First, we usually ask the patient where their pain is...and please...do not ask them their primary complaint, as we must consider all of their complaints. The issue with primary complaints arises with specialists who focus their examination on only one facet of the patient. As primary care providers with a focus on spine, we must consider the entire patient. The second problem is one of the electronic medical record providers. Most of them simply "do not get it" with program written by "non-doctors" or those who don't understand the full picture.
When I read a report that says the "the patient's first stated complaint", I want to VOMIT!!!! This is "computer – speak" and not a real person conversing on paper. Who talks like that? The answer… Nobody. Is this type of electronic reporting that can create problems downstream in your practice in a multitude of areas. In addition, what else are they programming into your reports that is just as egregious but hidden and will bite you in the ass downstream? You simply have to list the complaints and it is appropriate to go region by region, or with the highest pain number...but...it will be silly to list an 8 in the neck, a 7 in the low back and then a 4 in the forearm. Therefore I have always adopted a region approach in triaging my history.
To expedite the process, instead of the patient pointing to themselves or trying to describe in words what is going on, I simply ask to point on me what their pain is. I turn around and say "with one finger point to the pain area you have and trace a line if the pain radiates". If the pain is radiating into the gluteal area, I instruct them to point on themselves because the CAN REACH that area gracefully on themselves.
The overriding reason, the patient cannot reach their own backs and in one simple gesture, I get a firsthand account of where the pain is without having to interpret poor word choices because the patient isn't trained in describing pain. I then have my VAS (VISUAL analog scale) not the other VAS (VERBAL analog scale) with a picture of a "smiley face" at one end of the spectrum and "lightning bolts" at the other. As silly as a printed picture of pain scales might seem, this is an accepted standard nationally and in all courts. DO IT!!!
With a simple finger on me, I can now write in my own words to describe what the patient just showed me and save 5-10 minutes during the examination. I timed this process with former associates in my office and this step was a huge time-saver that makes the patient more comfortable because you do not have to press them for words they are ill-equipped to use.
The 2nd time consuming issue is explaining your services to the patient. Too many chiropractors spend 10 to 20 minutes per patient after the initial examination on the first visit explaining what the treatment is going to be. This is more prevalent with chiropractors who have "specialty care" procedures (such as chiropractic biophysics, advanced biostructural correction or any other type of advanced training).
This is a huge mistake.
In the consultations we give you a complete tutorial on the "report of findings" that should be followed almost to the letter. That is found in Consultation Section 4 titled "Office Systems and Admissibility" numbers 2, 3 and 4. If you do not do a written report of findings or show a video to your patients explaining your care I urge you to go back and read these brief sections.
On the first visit if the patient is in pain and you want to adjust them to relieve the discomfort, do so gingerly until you can explain the full treatment plan and what they should expect on every visit. A huge issue with patients are surprises and when they get care that they don't understand many people become afraid of the unknown and simply will never come back. Some patients will come back just to try it again to see how it feels and out of fear still leave even if they are feeling better. Some patients will feel so good, they will never come back because they were never explained the rehabilitation component and reconstructing the spine back to stability.
The unknown is a powerful negative motivator and with certainty will be the root cause of a failed practice.
The flipside of saying nothing is saying too much. Many doctors on the initial visit and during the evaluation try to explain their care to patients in such intricate detail that patients get lost or think you're trying to do a "sales job" on them. Patients are conditioned through the years of growing up in medicine that on an initial visit you get tested and on the follow-up visit the explanation is rendered as to the results of those tests. This is not only an efficient way of managing patients, it is also logical. You gather all the information and test results on day one and day 2 you render your explanation to your patients.
If you are spending more than 2 or 3 minutes during the initial encounter explaining your services you are wasting both your time and patient's time. If you say to the patient "Mrs. Jones on your next visit, which should be tomorrow we are going to put aside special time that takes approximately 30 minutes to explain both what your results are and what the plan is to help you get well". In over 30 years of caring for patients I can never recall a patient that didn't come back for the 2nd visit. Every patient wants to know what's wrong with them.
It is during this encounter, the "report of findings" that you will either make a compliant patient so they can get well or in the absence of a formal written report of findings leave the success of their care to guesswork, happenstance, luck or any other adjective that would describe uncertainty. It is my goal to stack the odds in favor of the patient getting well, which means following the treatment plan with all questions answered upfront.
NOTE: A verbal report of findings is the same as NO report of findings. The patient sill not remember.
These 2 simple actions of having your patient pointing to their pain and limiting your explanation of your care will save you a tremendous amount of time on your initial visit without compromising patient care.