A classic history and physical exam is a key component of the medical interaction and record of the patient and provider. The goal is a coherent, focused account of the visit in the chief complaint and history of present illness area of the chart. Electronic and paper charting templates prompt one to include the components for completeness and billing codes.
They are many techniques to obtain this information, but most leave out a crucial bit of information that may lead to higher patient satisfaction scores while dramatically speeding up the process.
This crucial component is patient motivation for taking the time out of their complex lives to obtain medical care that may take up to 6 hours and still not answer their questions.
Patients are motivated by multiple reasons:
- Fear of Illness - I was worried that I was having a stroke or heart attack!
- Family related - My spouse made me come.
- Accident or insurance related
- Problem that has persisted with no "magic cure" in sight
Asking the patient the circumstances and their concerns of the visit initially will narrow the scope of the visit dramatically. This allows the provider to focus on the acute problem at hand.
Eliminate the classic response of "You're the Doctor" - you should know and figure out what's wrong - and address their psychological needs.
Your patient will think you are an astute clinician who cares. Your satisfaction scores might go up and the #1 complaint of the provider didn't listen to me will go down!
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