Be Prepared

When I knock on the exam room door, after an ever-so brief pause to clear my mind from the constant mental clutter of my busy office, I want to focus only on my patient, and I want to be prepared.

That can be a struggle in today’s healthcare machine.

When a patient takes the initiative and asks for an appointment, the staff member on the phone can make the visit smooth instead of chaotic by making sure if there is something we have to get in preparation for that visit – an out-of-town emergency room report from the patient’s recent cross country trip, for example. Once the visit has started, the chances of getting records from an out-of-state hospital within 15 minutes are less than zero.

When I have asked the patient to come back, it is my team’s responsibility to be prepared. That means having a purpose for the visit stated in the schedule to give each of us a rough idea of what we need to do, and at least one of us will need to read the previous few office notes’ “Plan” to check the details.

We use words in my schedule that help define the visit. “FU (Follow-up) diabetes” means the quarterly visit with a glycohemoglobin drawn in advance with other lab tests or done with a fingerstick in the visit. “FU blood sugars” means we have already done the three-month visit and are bringing the patient back in to check the blood sugar log after some sort of treatment change.

“FU HBP” means a periodic, bigger, blood pressure visit that may involve other cardiovascular issues. “FU BP” is a quicker in-between visit to recheck a blood pressure that was high or to monitor a medication change.

Our EMR only offered scheduling options like “3 mo FU” and “1 mo FU”; that doesn’t help us prepare for the visit, so we worked around the vendor’s workflow to fit our practice.

The biggest challenge is to find the time for someone on our team to read the plan; it may mention tests we will do in the followup visit, an insurance or handicap form we promised to do next time, or it may mention that by the time I see a patient the next time, their long-awaited neurology consult should have taken place. If the report isn’t in, we still have a chance to get it in time for the visit if we call for it the day before or first thing in the morning.

We have had informal sessions before the first patient of the day for as long as I can remember. I have likened it to what a sports team or an airplane crew does before their job starts. Lately, in healthcare, the word “huddle” has become a staple in office workflow discussions. But not everyone in the business has embraced the idea of actually reading the last few office notes in each patient’s chart in preparation of each visit. In fact, some people seem to feel that only doctors should read the chart, even with all the talk about healthcare teams today!

Another big issue in reading the electronic chart is to review those items that are stored away from the clinical notes and test results; phone calls, at least in our system, are documented in a separate corner of the EMR, so that if I gave a patient a new blood pressure medication last month (lisinopril) and the patient called back saying their tongue swelled up, and I stopped the medication and maybe even prescribed a new one, that information is not part of the office visit sequence where I spend most of my time and attention. In a fifteen minute visit, many valuable minutes may be lost retracing such steps and events if the doctor walks into the exam room unprepared. Chart “prep” can make every visit smoother.

Today’s EMR notes can be challenging to read. For example, where in the old days I would dictate “Continue current medications and add amlodipine, 5 mg daily”, an EMR note today may automatically and with seemingly equal emphasis list seven refills and the new medication, so what is new drowns among the old. Unless I free-text in “add amlodipine to current regimen” or something similar, I can stare at the “plan” for a long time before discovering what was really new in the last visit.

Most patients probably think doctors remember things even without the record. I actually remember a lot more than I admit; I just don’t want to rely on my memory when a patient’s life and welfare is at stake and I have a million dollar system that is supposed to do the remembering for all eternity for me.

And, speaking of eternity, I have had a personal motto for many years, even before my temples started turning gray:

I try to add enough of my personal thinking, typed with two fingers after all the click-boxes have been checked off, so that if I should happen to meet my maker or perchance that big bull moose on Route One some day, my medical record and my team will make it easier for the next doctor in my position to take care of my patients.

4 Responses to “Be Prepared”

  1. 1 Lisa June 26, 2014 at 3:45 am

    Well, this explains a lot. I have often wondered why medications that I took for a short period of time for a specific purpose never seem to drop off the list. And I have also wondered why I have to tell the staff numerous times what blood tests I’m in for today when I come in for the same tests every 3 months. I love my primary care office, but sometimes I feel like they don’t remember who I am.

  2. 2 Robert Eanett, MD June 26, 2014 at 4:38 am

    This is almost exactly what I face each day. It is harder than ever to bring the whole patient into focus.

  3. 3 Ann Soutter June 26, 2014 at 2:38 pm

    that’s why in our office the RN (me) takes the time to review the schedule, and check the last few visits, and the phone calls to see why the patient is coming back. Other things, like when the patient was to return in 6 months, and they are back in 2 months can be red flags. Sometimes the patients are scheduled to see the MD when they only need a clinical visit with the nursing staff. Luckily, I am paid to come in early and get ready for the day. Makes it run much smoother for all of us.

  4. 4 Janine Calder, medical clerk June 26, 2014 at 4:44 pm

    I am making a career out of the chart research and interpersonnel/interdepartmental connections it will take to build proper patient care in this cold new EMR environment.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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