The Importance of the Consultation for any injury’s First Visit

An injury patient has entered your clinic, filled out paperwork, has given your staff insurance information, they are now ready to meet you, their doctor. They want to find out a few things. For example, How are you as the doctor? How concerned are you? How much time do you take? Am I important or is this doctor organizing a thousand different things in his head?  Your new patient can perceive these things, so you need to be switched ON!

So many doctors make the error of not understanding or stressing the importance of the very first consultation they have with an injury patient.  This is the first time that the patient’s going to interact with their doctor for any amount of time.  When a patient has a spinal ligament injury, 50% of these patients never fully recover, and of that 50% that don’t fully recover, 30% have a significant condition associated with it.

This person is literally turning over their life to you. It is up to you to make this a very, very important visit. This visit is also the visit that sets the tone for compliance, that sets the tone for how much they trust you, that sets the tone for how much they’re going to refer you to others.

                                Therefore, at that point in time, this patient must be the only thing in your mind. Your complete focus, razor sharp, should be on the patient.  As a priority, you must document every single symptom that they feel is associated with this condition. If they have head pain, stiffness, neck pain, back pain, arm pain, numbness, tingling, they don’t sleep very well, if they have cognitive dysfunction,  don’t feel like they’re thinking clearly, they feel like they’re foggy, they feel like they’re afraid of driving, they feel depressed, anything what so ever it may be, whether it be a list of 10 or 15 or 20 things, it’s very, very important that you get each and every one of them down.

To help you do so, we have in the Smart Injury Doctor’s Program, a form called a Smart Injury Symptom Tracker, and that Symptom Tracker allows you to put every single thing that the patient is saying that they have as a result of this injury in one simple, easy to use form

                                Take your time during this consult. Explore in detail all of the symptoms, how it effects them, their families, their co-workers. It literally takes minutes, but it’s very, very important. What your end result should be is a patient that feels completely duplicated and understood.

Another reason you do this so thoroughly is if you may miss a symptom and its details. For example, they may shoulder pain and you listed it.  On exam three days later, when you’re asking them how they’re doing or on a patient review form a month later and they don’t put the shoulder pain, you know they have improved. 

You only know this if exam was done in a systematic, thorough way. If a patient says, “I don’t know, I’m not doing that good.” You look at your list of 15 things that they listed initially. Now they’ve only listed seven things. That means eight of the things that they originally listed have dropped off the list. That’s the improvement that’s occurring, but because the patient still has these seven things, they don’t think they’re doing that well.

You need to have a way to track the symptoms so that each time you’re basically saying, “Hey, how’s the shoulder?” “The shoulder pain’s completely gone.” “Okay, initially you said headaches, but you’re not listing that you have headaches here now.” “Yeah, it’s pretty cool. I mean, I had headaches for two weeks, but the headaches are completely gone now.” They can see you care, you are interested in their improvement and can show that improvement has occurred. All of this by following a Smart Injury format.

                                A patient in that re- eval is going to feel more confident in his doctor if the duplication and documentation of his original difficulties are correct and the patient will be more compliant as well.  This patient will be telling all of his friends about you, talk you up to his attorney and this will all lead to more and more referrals.

Another important area is if the patient has any active preexisting conditions, things that they’re actively being treated for, under care for, that are in the same area or are very similar to what they have now.

                                So an example of that, the patient had neck pain a month ago and was seeing a doctor for this problem. At this doctor, they had taken x-rays, showing they had severe degenerative disc disease, began taking naproxen for this significant neck pain which the doctor had listed and diagnosed, and is now under active care and treatment. This is listed as an active preexisting condition.

An active pre-existing condition is uncommon. The majority of preexisting conditions are called dormant preexisting conditions. They too must be listed. You must list for example, if they are diabetic, have a high blood pressure, or have a problem with their weight.  Any number or pre-existing conditions can be a complicating factor in the patients treatment.

There will be a difference in results and the time of recovery between a 26 year old who has no body fat, works out at a gym three times a week and is a vegan and the person that say is 45 years old, has high blood pressures, is obese, doesn’t work out at all and has a horrible diet.

Another documentation factor is was there any delay or gap in care?  Find out and document what was happening. Were they actively treating themselves? They might say, “Well doctor, I didn’t think it was… I thought it would go away. I thought I could help it myself. I thought if I stretched, if I did ice, if I did over the counter medication.”All of these are active care procedures need to be listed because the patient was trying to do self care, which is active care. It’s a form of active care and it failed.

Another important consultation item is that you cover is ligament damage. In a  consultation it’s very easy to say, to transition, “In a moment we’re going to be doing an examination procedure and in that examination procedure I’m going to be looking for things to help me determine the severity and location of any injuries that you have.”

“Ligaments are the tissue that holds these vertebrae together and in alignment and when they’re damaged they can cause all kinds of problems. They cause instabilities to occur.” During  examination procedures you will to be testing for the effect of ligament damage. Specialized x-rays called stress x-rays will then determine the severity and location of any ligament injuries

Their confidence in you and your team will be so high if you properly assess their symptoms, duplicating documenting them.  Note any pre existing conditions, properly diagnosis and follow up with documentation of any changes and gaps in care. They will  feel cared for and tell their friends, their family, their attorney, their co- workers, and you and your staff.

It is so simple:

Become a Smart Injury Doctor

Use the Smart Injury Symptom Tracker Form

Note any Pre Existing Conditions

Do a comprehensive Examination

Use the Gap in Care Form as needed

If these things are done in a timely manner with total duplication of the patient and properly documented at the time of the event, is a time saver.  Never again say, “Oh, I’m in deposition now. I have to get all of my notes together.”

Join us, become a Smart Injury Doctor We would love to have you on our team.

For more information on Spinal Ligament Injuries please check us out at http://www.smartinjurydoctor.comor check out our SmartInjuryDoctors® Podcasts on Apple Podcasts, Spotify, Google Play or Stitcher.

For information on spinal ligament testing by board certified medical radiologists go to www.thespinalkinetics.com