As a health-care professional, I know deep down that my ideal work day requires regular servings of substance, texture and variety. It does me good to sink my teeth into challenging cases – it’s so satisfying when I help patients solve complex health problems.
Sign up to get the latest news and events from Canadian Chiropractor. Our E-newsletter will be sent to you only once per week, on Mondays.
Over the decades, I’ve come to the realization that there is one good habit that keeps me focused on the bigger picture, one simple thing that facilitates good case management and increases the chances of success.
It is something that can and should be a part of practice every day – a single piece of paper in a patient’s file that I believe is the most useful document of all – the written report of findings (ROF).
In its most basic sense, the ROF is simply what you say to a patient before you start treating them. And it’s not optional. Along with a discussion about the risks of care, “truly informed consent” requires that a practitioner share their findings with the patient, laying out a clear explanation of what they understand the problem to be and how the proposed treatment is expected to help.
Delivered orally, your report of findings is a chance to let the patient know you understand their problem and have real solutions to offer. It is also a great opportunity to reinforce the patient’s confidence that they’ve come to the right place with their complaints.
However, people often fail to hear your message correctly or completely. Human cognition is served best by repetition and reinforcement of key points. When your report is presented concretely and succinctly on a piece of paper that the patient takes home, it can have a significant impact on many aspects of your practice.
Here are some specific guidelines to consider and some very good reasons why you will want to make use of a written report of findings.
Handwritten or prepared as a printed document, you will want to use a standardized format with specific sections.
The most useful presentation employs the SOAP method (Subjective, Objective, Assessment and Plan).
- Brief summary of the history of their complaint – based on the details that have been gathered from their intake form, any special intake forms you use and the notes taken over the course of your new patient interview.
- Relevant physical examination findings – presented in layman’s terms; diagrams can be very helpful here.
- Diagnosis/Clinical impression – best expressed with the format: _____ of _____ due to ________. (eg. inflammation of lateral elbow due to overuse of forearm muscles or, tightness of left flank muscles with inflammation of left sacroiliac joint due to loss of joint play at the thoracolumbar junction).
- Treatment plan – be specific about the type of treatment you will be providing, as well as the frequency and expected duration of care; there should also be recommendations for self-care and, if applicable, referral to another health-care provider.
The header generally has all of your contact information, but don’t overlook the option to include a statement of purpose or highlight your special interests or important associations – it is a chance to advertise your services to everyone your patient chooses to share the document with.
View the embedded image gallery online at:
How to use it
- Give a copy to the patient at their next visit; keep a copy in their file. Take a minute or two to go over it with them and answer any questions they have.
- Share* it with your front desk staff – it is important for them to be fully on-board with the plan for the patient’s care
- Share* it with other health-care professionals who are part of the patient’s care team – the report can be used exactly as it is or serve as the basis for constructing a more detailed referral letter or an in-depth report for a third party.
What a written ROF is good for:
- It forces you to come to clear, well-informed decisions about the patient’s case – with enough confidence to put it in writin
- The information contained in a written ROF fulfills an obligation of regulatory requirements for clinical record keeping purposes.
- It’s a great marketing tool – it demonstrates to your patient and everyone who reads it that you are paying attention and know what you are doing.
- It increases the public’s understanding of how their bodies work and what doctors of chiropractic do. Our approach – how we think and the special skills we possess – is unique. More people need to know about it.
- It increases patients’ enthusiasm. When we make good communication a priority, patients are more engaged. When expectations are clear and they receive high quality care, loyalty to both us as individuals and our profession as a whole becomes a way of life for them.
This document broadcasts your competency and you’re also giving your patient the reassurance they need and the confidence they deserve from their healthcare practitioner.
Now, what if you are wrong about this patient? Perhaps your clinical impression missed the mark, or you were correct in your assessment but the treatment you provided didn’t achieve the patient’s goals. While it’s always disappointing to be wrong, good science demands that you recognize your mistakes and make corrections. Clinical proficiency is a moving target and all you can do is be willing to learn from your patients.
Keeping good clinical records, including a written report of findings, will let you review the facts and give you an answer to the question: “Was I on the right track?” This is the very foundation of evidence-based care – the gold standard for health practices.
If you measure your professional success in terms of good outcomes and a constant stream of referrals from patients and other caregivers (because the community understands that you know what you’re doing) then producing a written ROF for all of your new patients (and even your regular patients who present with a new complaint) is a winning strategy.
DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca.