Keys For Successful Participation
All components of patient care are being shifted from the in-hospital setting to outpatient clinics. Medical student education has subsequently changed to more accurately reflect this current state of practice. As such, you will all undoubtedly spend a significant portion of the next few years (as well as time during your residency training) seeing patients/learning in the outpatient setting. In order to be successful, you will need to adapt to this unique environment. The pace in clinic is less forgiving then on the inpatient services. In the hospital, you can always go back later to talk with the patient. Outpatients, however, are scheduled to be seen in a finite period of time, with little consideration given for the chaos that can occur when visits overrun their allotted slots. What sort of impact does this have on you as a student? While you will not be directly subjected to the pressures created by limited time and high patient volume, the same does not hold true for your preceptor. By extension, then, organization and time management will affect the quality of your experience, as measured by the amount of time spent with the preceptor, teaching which occurs, and number of patients seen.
How then do you learn to function efficiently in clinic? Preparation is key. Most patients attending outpatient clinics have been seen previously in the healthcare system. Important information about the patient is therefore frequently contained within the computer system, old charts, etc. In order to make best use of your time, you need to be aware of this information. I call this process "previewing" the patient and use the accompanying preview sheet (at end of section) to collect data and prepare for the visit. When participating in a clinic, try the following:
- Get to the clinic as early as possible so that you will have time to talk with the preceptor about your role/their specific expectations for you. Assuming that you will be performing the initial patient evaluation on your own, ask the preceptor which patients he/she wants you to see.
- Obtain the charts for these patients and find a quiet place to review relevant
historical information. Ask the preceptor where additional patient information
may be stored (e.g. computerized records, paper charts). When reviewing historical
information, pay particular attention to:
- The goal of the visit. If you are working with a sub-specialist and this is a first time referral, try to identify the question being asked by the referring provider. If it's a follow-up, determine which issues from the prior visit need to be addressed.
- Any active issues which are being addressed in an ongoing fashion (i.e. medical problems which mandate continued reassessment and/or are in the process of being evaluated). This would include problems such as coronary artery disease (which has a tendency to progress); diabetes; shortness of breath or fatigue of as yet undefined etiology, etc. Make note of these problems in the "active issues" section of the preview sheet . Past medical/surgical problems which tend to be static are noted in the PMH/PSH sections. If you are seeing a patient in a general medicine clinic, you'll need to pay attention to most of the active issues. Sub-specialists can obviously be a bit more selective, making note of only those problems that may be related to their field of interest. As such, preview sheets do not necessarily have to be filled out in their entirety.
- Current medications.
- Past x-rays/studies/labs. Try to focus on those that you think would be relevant to the clinic that you are attending (e.g. cardiology clinics will be interested in past echos and catheterization reports; pulmonary clinics in PFTs, etc). This data is obviously quite important. If you can't find the information that supports a purported diagnosis, make note of this as well, for it may represent one of the many instances where a patient has been labeled with a disease in the absence of appropriate documentation.
It should take 5-10 minutes to preview a patient. You'll get better with more experience, particularly as you develop a sense of what is truly relevant.
A Word About Style And Substance:
You will all quickly recognize that clinical education is a very heterogenous experience, particularly as it applies to outpatient medicine. Every physician with whom you work will have a different approach to history gathering, note writing, physical examination, diagnostic and therapeutic reasoning, etc. This actually makes perfect sense, as it reflects the fact that there are many ways of "skinning the clinical cat." That is, there is rarely a single, correct way to care for patients. Rather, there are usually a wide array of acceptable approaches, any of which may be appropriate. For students, however, this "clinical richness" can be quite disorienting. Lessons learned in the morning may at times seem contradictory to that which is taught in the afternoon. Instead of viewing this as a negative, I would suggest that you look at it as a great educational opportunity. The actual practice of medicine is as much about style as it is about science. This will be one of the rare moments in your careers when you will get direct exposure to an array of clinical approaches, each of which is likely to be effective in its own right. During these years, you will have to work within the rules that govern a particular practitioner's clinic. While doing this, try to understand the logic behind their practice patterns. Ask yourself if it makes sense and is therefore something which you should permanaently incorporate into the style that you are trying to develop for yourself. Don't lose track of the fact that this is the ultimate goal of these exercises.
Meeting with the Patient:
After examining all of the data, begin the interview by confirming the reason for the visit. Then review all of the historical information that you've uncovered during the previewing process. This provides an opportunity to correct any misinformation/misperceptions that may have been generated. Additional history taking is approached in the usual manner.
At the completion of the interview, leave the room and allow the patient to change into a gown. Return and perform the physical examination, noting the vital signs as well as any pertinent findings on the preview sheet so that you will not forget them. Each visit does not necessarily require a complete physical. Frequently, a focused exam (e.g. a detailed knee evaluation in a patient complaining of pain in that area) is entirely appropriate. Remember, not every patient needs/requires a complete H&P. This would neither be efficient nor revealing. Instead, use your judgment and check with your preceptor for guidance. At the end of the exam, leave the room (or at least pull the curtain) to provide privacy while the patient changes back into their clothes. Take a few moments to think about the information that you've gathered and use it to generate a focused assessment and plan (see below). Depending on your preceptor's practice style, you may either present the case in front of the patient or in private and then go in together to review the details.
At the end of the visit, the preview sheet contains all of the information that you've gathered both before and during the examination. In addition, it can include a brief assessment and plan for each problem (as discussed below). This leaves you with an inclusive reference document for use in writing your notes at the end of the visit. It also provides a structured means of keeping track of information while at the same time allowing you to focus your attention on the patient during the course of the H&P. The type of note which you write varies with the clinic and reason for the visit. For example, first time visits to an Internal Medicine Clinic are similar to a complete H&P (see that section of the Practical Guide for details). Follow-up notes or those for subspecialty clinics, on the other hand, are much more focused. I'd like to highlight a few special features that I think are particularly relevant to outpatient visits:
Purpose of the visit: Mention at the top of the note why the patient has come to the clinic. This could include: First visit for general care; or routine/scheduled follow-up; or add-on/urgent visit to address a specific concern/issue; or sub-specialty visit to address a very particular problem; etc.
Medications: I generally review the medications that the patient is taking, and then list them at the top of the note. Medication confusion/non-compliance is a major clinical problem. By reviewing the list each visit, I can try to make certain that the patient is taking meds as prescribed. And, if there is confusion/a problem with compliance, I can at least be aware of it and attempt to address it. To minimize confusion, I would suggest using the generic names for medications (in addition to listing the dosing strength and interval).
Issues/Events: Rather then beginning with an "HPI" or "Subjective" section, I start outpatient notes by describing recent/important "Issues/Events." These can include:
- Any new symptoms that the patient is experiencing (e.g. cough, low back pain, chest pain etc), which is described in the usual "HPI" format.
- Specific concerns that the patient may have (e.g. patient initiated discussion about the role of cancer screening test, cholesterol measurement, etc).
- Review of data/symptoms of disease states that the patient is known to have. Patients with diabetes, for example, will usually record their blood sugars. This information can be mentioned here. Or, if the patient is known to have coronary artery disease, I might record presence or absence of angina, exercise tolerance etc in this section.
- Events: This includes any important clinical happenings that have occurred since our last visit. For example, trips to the emergency room (including reason for visit and outcome), visits to subspecialists, hospital admissions, out-patient procedures (e.g. radiology studies, invasive testing), etc.
An Issues/Events section is simply one way of organizing historical data in a user friendly/functional fashion. Note that disease states which generally don't generate symptoms (e.g. hypertension) are not mentioned in the Issues/Events section, as their treatment is not usually directed on the basis of subjective measures. In the case of hypertension, for example, thiswould be based on measured BP, which is an objective value noted in the VS.
For many patients, the Issues/Events section may be left blank (e.g. young, healthy patient presenting for annual follow-up).
Examination findings, lab/x-ray results, and assessment/plan are written in the same fashion described in the "Write-Ups" section of this guide.
A Few Other Thoughts:
Some practitioners actually write or type their notes while simultaneously obtaining the history. With time, you may develop skills that allow you to do this without compromising your attempts to establish rapport and listen closely to the information that the patient is trying to convey. At this stage, however, I believe that this approach is too distracting. Instead, pay attention to the patient while taking written notes of important details. These can later be typed into the formal note.
I should also mention that, in health care systems that use computerized records, there is a growing tendency for practitioners to "cut and paste" data into their notes. In particular, this may be done for lab tests and radiology reports. I would discourage this practice (at least early in your careers) as it is a bit mindless. Rather, I would prefer you to look through the labs and studies, and ask yourself: "Why were these tests done? What critical information do they make apparent?" Cutting and pasting a normal CBC into your note (complete with the MCHC, RDW etc) requires no thought and contributes little important information. I would much rather you review the labs, identify that the cbc was normal, and then simply mention "normal CBC" in the note. Similarly, if a study is abnormal, think about what particular elements are amiss, and highlight them, which should present the data in a workable/usable format. It may take experience/practice before you figure out what it relevanat (and why), but at least the above system will force you to think!
Some computer record systems make it possible to "cut and paste" another clinician's history into your note. I would strongly discourage this, as the note is your opportunity to present the Hx as you saw it, to provide your own spin to the story.
The Assessment and Plan:
There are many ways of approaching clinical problems. You might find it helpful, particularly when dealing with complex clinical issues, to break each problem into its most basic elements, with a separate plan noted for each one. By identifying the most basic components of each problem, you will be less likely to miss important issues and be better able to devise the most inclusive/complete plan possible. Your ability to do this will obviously vary with your experience and knowledge base. However, this general approach applies to most clinical situations. Let's take, for example, a patient who presents with new dyspnea on exertion who also has known coronary artery disease, CHF, hypertension and hyperlipidemia. Each one of these problems is related to the patient's cardiovascular system. However, if you were to address all of them under a single "cardiovascular" heading, there is a good chance that the assessment and plan would become jumbled and confusing. These problems could, instead, be broken down as follows:
Dyspnea on Exertion: Patient with mild decrease in exercise tolerance. No symptoms of angina (which was associated with left-sided chest pain in the past). No exercise induced desaturation noted during observed 3 minute walk in clinic. Nothing on exam to suggest CHF. Patient has significant smoking history, though not known to have COPD, and no current wheezing on exam (no past PFTs). Smoking also puts patient at increased risk for pulmonary malignancy, though no other suggestive symptoms. Etiology of dyspnea not clear. In any case, not obviously debilitated by symptoms.
- Obtain PFTs
- Obtain CXR today
- CBC to r/o anemia as cause
- Re-Evaluate in clinic in 6 w (or patient will call sooner if symptoms worsen)... at that time will consider repeat Exercise Tolerance Test to asses for ischemia/quantify exercise tolerance; also consider repeat echo to reassess LV function.
Coronary Artery Disease: Known coronary disease. Patient continues to be active without symptoms.
Plan # 2:
- Continue aspirin and lopressor (beta blocker)
- Patient aware of symptoms suggestive of recurrent ischemia. If occur with activity, will repeat Exercise Tolerance Test.
CHF: Known depressed left ventricular function on basis past MI, with EF 30% by last echo. No symptoms for over 1 year since initiation of medical treatment.
- Continue Lisinopril (ace-inhibitor) 40 mg/d
- Continue lasix (diurectic) 40 mg/d
- Check potassium, creatinine today
- Repeat echo next year, unless symptoms/exam more clearly suggest worsening CHF
Hypertension: Well controlled. End organ dysfunction (CHF and CAD) managed as above.
- Continue medical treatment as above
Hyperlipidemia: LDL 80, HDL 40 both at target levels on Simvastatin (HMG-COA Reductase Inhibitor) 20 mg/d.
- Continue Simvastatin at current dose
- Check parenchymal liver enzymes (alt/ast), Creatinine Kinase today and in 6 months to assure no toxicity.
Heath Care Maintenance:
In a general medicine clinic, it's helpful to conclude each note with a Health Care Maintenance section. This includes age and sex specific screening tests as well as vaccinations that are otherwise easy to over look.
For men this would include (roughly... the following are not necessarily the definitive guidelines):
- Consideration for checking PSA (African-Americans beginning age over 40; Others over 50)
- Colorectal cancer screening (age over 50 and every 5-10 years thereafter)
- Annual PAP smear (beginning at age of sexual activity)
- Annual Mammography (beginning at age 40 or 50)
- Colon Cancer Screening (with flex sig. or stool guaiac cards as above)
- ? Bone Density Assessment (based on risk factors)
- Flu Vaccine (annually)
- Pneumovax (age over 64 or those at risk)
- Tetanus (every 10 years)
Follow-up is mentioned at the conclusion of the note. Selecting the appropriate interval between visits is not very scientific. As such, you will see wide variation among practitioners, varying with accuity of illness, complexity of care, and experience of the clinician. Perhaps more important is identifying the appropriate situations for initiating contact as well as the preferred means of communication (e.g., telephone, email, snail mail, etc.).
You will find samples of an initial/full clinic note, repeat visit note for the same patient, as well as a completed preview sheet later in this section.
The system described above represents one particular organizational approach to outpatient care. There is a lot of room for variability.
BLANK PREVIEW SHEET
COMPLETED PREVIEW SHEET
SAMPLE CLINIC NOTE-- INITIAL VISIT
First visit to me for this 56 yo male, formerly cared for by Dr. M.
to receive all medical care from me, and sees no other/outside
Supposed to be taking: Diltiazem 60 tid; Fosinopril 20 qd; Glyburide 10 bid; Metformin 500 bid; Aspirin 325 qd; Gemfibrozil 600 bid; isordil 10 tid.
Actually taking: Glyburide 5 tid; Aspirin 325 qd; Fosinopril 20 qd; Diltiazem 60 tid.
- DM: Known x 2y with poor control over that time (alcs around 10). Patient confused about meds. Claims has met nutritionist, but no education classes. No hypogly events. Has glucometer, but does not check finger sticks.
- Chest Pain: Reports very brief episodes (ie lasting 1-2 seconds) of L sided chest discomfort. Not like past mI. Not associated with activity. Can occur up to 3x/w. Then may not occur for weeks. Sometimes takes TNG for this, othertime not. No increase in frequency. S/P PTCA (?which vessel) in 93 at Sharp. Presented at that time with new onset of severe cp, diaphoresis, sob. This was a relatively brief episode, with resolution of sx prior to angiogram. Unclear if his MI was at this time or prior (though no similar sx prior). No episodes/sx CHF. Last ETT-Thal at VA 95...8 mets, fixed inf-septal defect; small distal inf-septal area reperfusion (5% of myocardium).
- ER Visit: Went to the emergency room about 1 month ago after having fallen approximately 5 feet from a ladder, landing on right ankle, with significant associated pain.. Had x-rays done that were negative for fracture (per patient). Pain in ankle now completlly resolved.
PMH: Diabetes (details as above)
CAD (details as above)
PSH: S/P Appendectomy 88 Smoking:
Other substance use:
30 pack year, quit 10 years ago.
2 beers per week
SOC: Not working currently, though wishes to go back to work doing light construction. Enjoys reading and hiking. Married x 15 years. Two children, ages 10 & 5, both well.
Sexually active with wife, no problems with libido or erections.
Family: Father died from MI, age 50; mother alive, age 65, though Hx DM (onset 50), stroke age 60. One brother, two sisters all well. No family Hx cancer. PE: Overweight male, NAD
154/81 76 wt 208
C/V: s1 S2 no S3 S4 1/6 sem c/w aortic sclerosis
ABD: Soft, nt, no masses
Rectal: Brown stool, g neg; prostate nt, no nodules
GU: Testes descended bilat, nt, no masses; no hernia
Ext: no c/c/e
Labs and Studies of Note:
09/98: T Chol 344, TG 651, HDL 48 (NOT FASTING), Cr 1, Glu 268, LFTS nl; UA + Protein, Alc 9.8
1/98: A1c 10, Glu 300
R Ankle Xray 8/98: neg
ASSESSMENT/PLAN: 1. DM: Very poor control and very poorly informed, though willing to learn. Not actually taking metformin and on wrong dosing regimen for glyb. Ned to readdress all areas of care.
- Will arrange DM teaching
- Glyburid 10 bid
- No metformin for now (he's not taking it in any case). Assess response to glyburide and then add back...will also allow for simpler regimen, at least initially.
- Instructed to take fs 1x/d, alternating btwn pre-breakfast and pre-dinner
- Has proteinuria...on ace-i... addressing better control as above
- Had eye exam 6m ago.
2. CAD/Chest Pain: Not sure what these 1-2 second episodes of chest discomfort are. They do not sound anginal. Not a worrisome pattern, given fact that no increase in frequency, not with activity. However, patient is not the best historian and certainly does have CAD.
- Will arrange for ETT-Thal to better quantify ex
tol, assess for
- Start atenolol 25
- Cont asa
- Given bottle for fresh TNG s1, in case...
- D/C isordil (not actually taking, anyway)
3. HTN: Suboptimal control
- D/C Diltiazem
- Fosinopril and atenolol as above
4. Hyperchol: Can't interpret lipids in setting non-fasting state.
- Repeat profile on 12 hour fast
- D/C gemfibrozil (he is not taking it anyway)
- Would benefit from statin if LDL > 100...also would certainly benefit from better glycemic control... to be addressed as above.
5. HCM: Tetanus and Pneumo Vax 97.
- Address ? Colorectal CA screning, PSAon f/u visit.
F/U: 1 Month
SAMPLE CLINIC NOTE-- FOLLOW-UP VISIT
F/U visit for this 56 year old male, last seen by me 9/18.
MEDS: Glyburide 10 bid; Aspirin 325 qd; Fosinopril 20 qd; Isordil 10 tid; Atenolol 25 qd.
- DM: Taking glyburide as directed. Also brings finger stick log, which reveals AM readings (pre-breakfast) 180s, PM readings (pre-dinner) 200-210. No hypoglycemic episodes. Attended first of 4 DM education sessions and met with nutritionist. Repeat hemoglobin A1C obtained last week = 9.
- CAD: Just underwent ETT with Thallium (/98. Achieved 8 met
becoming symptomatic. Thallium reealed fixed inf-interal
defect. No areas
of ischemia. Has been working doing light construction and has
had no chest
pain, so, other. Has not used any sub-lingual TNG. Denies PND,
No other complaints.
PE: Well appearing, NAD
150/90 76 wt 210
HEENT: no JVD
C/V: s1 s2 no s3 s4 1/6 sem c/w aortic sclerosis
ABD: Soft, nt, no masses
Ext: no c/c/e; no ulcers
LABS: Fasting lipids 10/22/98: T Chol 270, TG 300, HDL 40, LDL 170. ASSESSMENT/PLAN: 1. DM Better control now that taking glyburide as directed though still sub-optimal. Appears compliant. Following thru with DM classes.
- Continue glyburide at 10 bid
- Add Metformim...start with 500 qam x 1 week; then 500 bid...aware of side effects (i.e. GI sx) and will call if intolerable.
- Continue with DM education program.
- Check hemoglobin A1C in 3 months.
- Continue keeping finger stick glucose log...can take readings pre-breakfast one day alternating with pre-dinner the next.
- Has proteinuria but already on ACE-I (fosinopril 20).
2. CAD/Chest Pain: ETT reveals no ischemia at reasonable work load. Still with BP to work with.
- Increase atenolol to 50 qd.
- Continue asa 325 mg
- D/C Isordil as no evidence of ischemia on ETT or chest pain
3. HTN: BP still up. Compliant with meds.
- Meds as described under CAD
- If high on f/u, increase Fosinopril to 40 - target BP 130/80
4. Hyperepidemia: LDL above target of 100 in patient with known CAD.
- Start Simvastatin 20 mg qhs.
- Baseline alt/ast, ck nl (as of 8/98). Repeat alt/ast in 3 m
- Repeat fasting profile in 3m. Increase Simva to 40 if not at target at that time.
- Patient aware of other side-effects (e.g. myositis, GI upset). Will care if they occur.
5. HCM: Vax up to date. Discussed PSA and flex sig and wishes to proceed.
- Obtain PSA today
- Submit consult for flex sig.
F/U: With me 3 M