I was recently asked my advice on a complicated patient.
Although the patient was young in age and active, their past medical history read like Evil Knieval's (again I am dating myself). The therapist provided a through past medical history in about 3 pages of text.
Obviously both he and I understood that there were numerous areas with the potential for treatment, the question was where to start.
In spite of the therapist's complete description of the patient history, he forgot to include what I feel to be the most important component of the Subjective history. Questions that will be used to not only guide the evaluation, treatment, documentation and progress, but it will let the clinician know where to start, especially with complex patients.
It is:
"What activities cause your pain and what activities do you have difficulty performing or can you not perform?" If my patient is being evaluated for balance and falling I then ask: "What were the circumstances of your falls or what activities cause you to feel off balance?"
This is usually is the first question that I ask when I meet my patient for multiple reasons:
1. I will now be able to provide functional goals for my documentation which are vital for insurance reimbursement.
2. I can direct my evaluation to determine why a person is having pain or an inability to perform a task by; taking that activity, breaking it down into its component parts, and evaluating each one. This will almost always show me the patient's dysfunction that is causing their functional problem or pain. As a result I now know where to start and what to treat. As a result, I can make significant gains in one visit.
3. While past medical history is important to avoid performing therapies that are contraindicated and understanding mechanism of injury, patients can spend their entire evaluation time telling you their life story. In today's healthcare setting we simply don't have the time and this information can be listed by the patient on their intake form. I prefer to ask direct questions regarding these factors so I am in control of the conversation and can specifically ask the factors that are appropriate for their care right now.
4. While pain often inhibits ones ability to function, once the painful activity has been established, both the patient and I can determine their progress by the patient's ability to perform a certain activity rather than ask "how are you feeling?"
5. Their past medical history may not be a factor in their current functional deficit.
My greatest success using this process of evaluation was on a patient who had sustained multiple falls resulting in fractured bones on 2 separate occasions. When I asked the circumstances of her falling, I had her safely repeat that motion. When she performed it, I observed that 1 of her feet was coming off of the ground prematurely.
Therefore, the reason that she was falling was that she was losing her base of support with only a slight weight shift.
I then determined why it was happening and treated her in one visit.
In the 3 years since that 1 evaluation and treatment she has not fallen.
It is interesting to note that this patient's fractures were on the opposite side of her dysfunctional foot and if I based my treatment on her past medical history, I would not have been treating the correct side of her body.
If you are not already asking these questions during your Initial Evaluation, give it a try, it is guaranteed to save you time and money while avoiding frustration and confusion.
