The Consultation Step Three: Obtaining A Comprehensive Case History By W. Karl Parker, B.A., D.C., F.I.C.C., F.A.C.C. e-mail: behapy@karlparkerseminars.com Only when you have established rapport, is it time to gather information and get specific details by conducting a comprehensive case history examination. Begin the case history with your „setting the stage¾ script ending it in a statement similar to the following: "Mrs. Patient, I have studied the information on your patient information form, and I want to know everything about your (chief complaint). Show me exactly where it hurts¾ (or, "tell me about it."). While making this statement, the doctor should lean forward, make eye (according to the patient's preference), touch pain points (if appropriate), and then set back in the chair ready to listen to the patient answer your questions. Give the patient your full concentration, listen intently, be a "big ear." Give the patient signs of acknowledgment. Nod head in the affirmative to show the patient you agree with what they are saying. Also, use verbal acknowledgmentsã„I see,¾ „I understand,¾ "Yes," "No." It is important to let patients purge themselves of their problem to the point where they feel the doctor completely understands how they feel. It is also important that the doctor stay in control and not let the purging drift into areas of conversation that are inconsequential or even unrelated the patient's problem. If the patient starts to talk too much on these unrelated points, guide the consultation by making statements and asking questions similar to the following: "Just a moment, Mrs. Patient. This information is very important and I would like to write it down." Then after making a note of their last point, regain control by asking pertinent questions. Make extensive notes. Writing notes during the consultation shows interest. The notes should include the patient's words as well as the doctor's technical description. This information may be used for a patient report as well as helpful in narrative reports contact and expert witness testimony. Repeating the patient's own words in describing their condition helps assure the patient that you understand their problem. As you gather information from the patient, keep in mind that there are two important end results of data gathering: 1. Diagnostic --A good case history is very helpful in discovering the cause of the problem and determine appropriate treatment. 2. Educational -- Well performed consultations are helpful in leading patients to discover some of the principles of chiropractic. Thee patients can learn that there must be a to cause inside their body which allowed or perpetuated the health problem. Survey information on all chief and chronic complaint(s) using the following 11 points. A mnemonic system for these important points has been developed for ease of use in the office and on office forms such as those in your ChiroSource forms book. The most updated "Patient Consultation" form we have provided you for use using the Parker WayÅ does not list these initials, but all these points are covered in a more easily guided manner leaving less for you to learn and memorize. The 11 points below will serve to help you fully understand the most pertinent data to gather from your patients during your consultations. 1. P.O.P.- Position Of Pain. a. Precisely note the patient's symptoms. 1) Exact location. 2) Type of symptom: constant or intermittent, ache or pain, dull or sharp, shooting or steady, numbness or tingling, tense or tight, weak or strong. 3) Other information regarding the symptoms: How long does it last? How often does it occur? Is it becoming worse, improving or remaining the same? Is there anything that precipitates it (brings it on)? 4) Ask additional questions to show your awareness of the problem and to explore differential diagnosis and determine the extent of the condition. b. Besides writing a word description, also use a red pen and note the information clearly on the human figure of the consultation form. 2. D.O.C. Duration Of Condition. a. It is important to find the true beginning of not only the symptoms but the cause of the present condition. Ask the patient when they first noticed any aspect of the problem b. Dig for chronicity; establish the cause which usually occurs long before symptoms by asking questions similar to the following: "Have you ever had this or a similar condition before? Think hard as a child, a teenager?" "How long has it been since you really felt good?" "Do you have muscle spasms or twitches? Where?" Etc. c. If patient is unaware of any chronic history of their condition, ask questions related to symptoms that are common in that area. For example, a patient with headaches often has sinus, hay fever, etc., but never thinks of chiropractic. Also, check the Patient Case History form the patient completed for related symptoms. 3. N.L.W.- Normal Living and Working. a. Search for normal daily activities that affect the patient's condition, both positively and negatively. b. Note inability to perform normal functions. 4. A.E.P.- Adverse Environmental Possibilities. a. Determine whether or not the patient believes that something in the environment contributes to his or her problem. b. If patients reveal their belief that the environment ("Pollen caused my allergies") or the symptom ("I believe I have bursitis") is the cause of their problem, relate the patient's belief to being actually an aggravating influence to the true cause, if true. 5. H.P.- Hereditary Possibilities. a. Determine any direct hereditary effects related to the patient's condition. b. Determine any relationship problem to "acquired-by- lifestyle" traits that might affect this person's condition. c. This information is best obtained by having the patient complete a "Family Health History Record" form. After inquiring into this area, tell the patient you need this form completed and returned on the next visit. The CA can present the form at the conclusion of the visit. 6. P.S.F.A.- Previous Surgery, Falls and Accidents. a. Note all past traumas that might have caused, precipitated or affected their spinal condition. b. Determine relationship between patient's traumas and the duration of condition. c. Note all previous surgeries. 7. N.O.D.- Names Of Doctors. a. Note names of all doctors seen for the present condition or any similar condition as well as the name of the patient's usual family doctor. b. Determine dates of last visit with previous doctors. c. Never make derogatory remarks about another doctor. Instead use hearsay praise: "I understand Dr. Jackson has a good reputation." Remember, you never build yourself up by putting someone else down. Also, when you praise other doctors who have not helped the patient, consider what it makes You...when You do! d. Determine if patient has seen another doctor for anything, recently. Other problems not presently active may give information about present condition. 8. P.D.- Previous Diagnosis. a. Determine diagnosis of each doctor seen for the patient's present condition. b. If the previous diagnosis is merely a name for the symptoms of a condition, (i.e., bursitis) then probe to determine what the previous doctor's opinion is of the cause of that condition. Of course, there usually isn't any, except possibly environmental, and the patient can subtlety be made aware of that fact. 9. F.T.- Former Treatment. a. Note all types of treatments performed or recommended by other doctors seen for this condition as well as the effects of that treatment. b. Determine if patient has done anything else, even home remedies which they feel have been effective or ineffective. c. If patient has had previous chiropractic care, whether it was for this condition or not, note the types of treatment administered and the results. d. Note any medication or nutritional supplementation that the patient may be presently taking, whether or not it is for this condition. Be sure to obtain exact names, dosages, and the reason for taking the medication or supplementation. 10. L.O.T.- Length Of Treatment. Note the length of the treatments previously administered. 11. Other information. a. Determine why patient quit previous doctors. b. Determine former examinations performed by previous doctors in order to make their diagnosis and determine their treatment program. c. Ask patient about other health problems. d. Make a note of patients' fears regarding their condition and evaluate the case to alleviate those fears. Add this information to your report of findings and also implant concept of chiropractic prevention methods. e. Give the patient a last opportunity to tell you anything else about their condition before concluding the consultation. The importance of a comprehensive consultation and case history cannot be over emphasized. Following the 11 point case history format will guide you in getting the necessary information to help you with your diagnosis and treatment program. This format should be followed for each separate condition. Each individual patient is different and the 11 point case history is just a guideline. You may need to ask many questions of an individual patient that are not specifically covered in the 11 points.