practice Pearls

Document a SOAMP note

I have discovered that a minor adaptation of the SOAP note format clarifies my documentation of patient visits. I add "M" for medical decision making, which creates a SOAMP note. The addition of this section prompts me to document discussions with other professionals, additional history obtained from family, and lab, radiology or other reports I reviewed during the visit. Improved documentation of data review sometimes enables coding a higher level visit, and this format makes all the elements required by the Documentation Guidelines for Evaluation and Management Services readily evident for any reviewer or auditor: history (Subjective), physical exam (Objective), diagnoses (Assessment), data review (Medical decision making), and treatment (Plan).

Terry L. Mills Jr., MD, FAAFP
Newton, Kan.

Cross train your staff

Cross training your staff can help your practice more easily adapt to changes in patient demand and staffing fluctuations. Cross training allows staff members to assume different responsibilities, and it enables smooth, constant support for the providers. For optimal flexibility, cross train office and nursing staff to perform one another's tasks where appropriate. For example, office staff can learn to clean medical instruments, set up exam rooms, assign patients to exam rooms and speak with patients about the reason for their visit. Nursing staff can learn to schedule, reschedule and cancel appointments.

Source: Institute for Healthcare Improvement.
Optimize the care team: cross-train staff.
Available at: http://www.ihi.org/IHI/
Topics/OfficePractices/Access/Changes/
IndividualChanges/CrossTrainStaff.htm.
Accessed Feb. 5, 2007.

Observe patients before their exams

I find it helpful to listen and observe as my patients are checked into their rooms. While I am busy charting, I can catch a glint of conversation and maybe a chief complaint, and I can get information about the patient's gait, strength and overall level of illness. The fact that an otherwise healthy octogenarian is being assisted up the hall and is breathing heavily spells one kind of trouble, while the peculiar gait of a young jogger may tip me off to Achilles tendonitis or an inflamed iliotibial band. It is like getting a preview of what is to come - not only in regards to my patients' acuity but also to their mood.

Kevin Elder, MD, FAAFP
Tampa, Fla.

Role-play with children

Head, ear, nose and throat exams of children can be challenging when the patient is scared or uncooperative. I calm the child's anxiety by demonstrating the exam with the child's parent or stuffed animal first. For example, I look into the parent's ears and nose, ask the parent to say "Ahh," and elicit a smile from the parent afterwards. This role-playing builds trust and rapport when the child sees that the exam is not painful or scary. This helps the exam proceed more smoothly for everyone.

Hien Nguyen, MD
Fairfax, Va.

Use online resources to address patient concerns

With computers now in our exam rooms, I often use Google.com to quickly search for images of common diseases when the patient does not understand the disease process. For example, practically every patient with a red spot on the genitalia is certain he or she has herpes. Showing the patient a photograph of what a herpes infection looks like helps to dispel misconceptions.

Nate Hitzeman, MD
Sacramento, Calif.

Manage patient encounters away from the office

I often encounter my patients away from the office. Many times, a patient will begin a conversation centered on his or her medical problems. I've found a few strategies that help me avoid giving medical advice in these less-than-ideal circumstances:

• I tend to talk little and listen more.

• I offer noncommittal but validating remarks such as, "This obviously causes great concern to you" or "It must be quite disturbing."

• I suggest that we explore the patient's concerns further at the office.

• I record the encounter in the patient's file.

Basil Rodansky, MD
Woodhaven, Mich.