Once you’ve mastered the first set of efficient office rules, it’s time to get to business. You want to make the most of your office visit, after all, in case you didn’t get the point. The key here is, “Don’t waste time.”
So the first thing you need to know how to do is: Give a History.
Remember, the medical doctor has to document your encounter in the record, which can be terribly difficult. This documentation is ostensibly in the interests of clear thinking and responsible record-keeping. (But a lot of it is to please the chart-review trolls who inhabit the dungeons of health insurance companies). We have been trained to extract your story and record it in a very specific manner (without the assistance of bamboo splints under the fingernails or electric shock). It’s called a SOAP note (more on this in a later blog).
Here’s how you do it. Remember: 1 – what, 2 – where, 3 – associated symptoms, 4 – time factors, 5 – influencing factors.
First, the “what”. What is your “chief complaint”? This should be delivered concisely in as few words as possible and should consist of a physical or emotional symptom, such as, “pain” or “cramping”, “tingling”, “anxiety”, or “homicidal urges”. Please try to avoid long pre-ambles like… “my husband’s Aunt Eunice was coming to stay for the week…” (That’s later, under influencing factors for “homicidal urges”) Here is the place also to use qualifying terms like, sharp, cramping, aching, burning, etc., and quantifying terms like: “bad, really bad, really, really bad, etc. (Avoid unprintable expletives. I can’t document those anyway.)
Next, the “where”. Where is the symptom? Again, be concise… “my head”, “my feet”, “my stomach”. (Avoid terms like “everywhere” unless it’s absolutely necessary… it drives us doctors nuts).
Next, are “associated symptoms”, like “nausea”, “fatigue”, or “weakness” that accompany, precede, or follow your chief complaint. (Again, avoid informing me of the associated pain in your “nether regions”… who is named “Aunt Eunice”. This may be relevant to you, but it rarely helps me make the diagnosis).
Next are “time factors” like: “every morning”, or “all day”, along with duration and or frequency of symptoms like: “constantly” or “intermittently, “for a few seconds” or “for hours at a time”. Also most important for time factors is when these symptoms first appeared. (We doctors go into panic mode when you say, “I’m having the worst headache of my life”… then don’t know whether to be relieved or irritated when you say, “I’ve had this for months.” )
Finally, there are the “influencing factors”. These would include such things as: “when I eat a fatty meal”, or “when I climb a flight of stairs”, or “when I reach up or bend over.”
Here is where you can mention Aunt Eunice.
Stress can be a real killer.