Today every therapist is experiencing the demand to do more in less time. With documentation requirements, administrative burden, billing and productivity expectations the load often feels overwhelming.
Perhaps the one visit that creates the most difficulty is the initial evaluation. You must have finished your patient in the time slot right before the eval. You must complete the eval and get some treatment started on that first visit. Then be ready for the scheduled patient in the next time slot.
In this blog we’ll discuss what should happen in your initial evaluation and how to get the most out of that first visit for you and your patient.
A crucial theme throughout this article is the importance of forming a strong relationship right from the start with your patient. That relationship begins with the very first interaction. Your greeting of the patient, your opening comments and explanations all set the tone for your future together.
Smile and Introduce yourself with your first and last name. Then give them just a brief explanation as to what’s going to happen. This type of interaction reduces their anxiety and says everything to the patient about you and how you plan to work with them.
One of the most crucial issues in forming that early relationship is for that patient to get a sense of feeling heard. When one senses their provider is truly listening, they get the feeling they are important to that provider. Theodore Roosevelt said, “Nobody cares how much you know until they know how much you care”. If you want them to sense you care, then listen carefully. This is the perfect time to employ your active listening skills
If you need a reminder here are some active listening hints:
While staring at your computer isn't advisable, do make sure to document answers the patient provides you into your EMR. It's impossible to remember everything that every patient tells you but having some notes will help you in the future and can really help you guide the patient to a positive outcome.
Research has shown most of the information necessary to make a diagnosis is provided through the patient’s history. Obtaining an accurate history from the patient allows you to begin to formulate your preliminary diagnostic hypothesis. Just from the history you should be able form a list of most likely diagnosis. Later you will work to narrow down as you go along through the examination.
Obtaining a good history is, to some degree, an art. Your primary goal is to be sure you understand the extent of the patient’s problem and their desired outcomes. Also make sure you are clear on what they need from you. You should be customizing the history questions that you ask and tailoring them to the patient and injury, as well. Your EMR should follow with you allowing for customization of fields to align with your evaluation.
The first thing is a review of systems. Depending on the patient this could be simple or complex. Assessing the potential impact problems with other system may have on your treatment cannot be overstated, particularly with older patients. Missing critical system issues is avoidable, so make sure you have effectively review for any problems.
You’ve obtained the history, now your examination can now follow. The initial content of the exam needs be guided by your initial diagnostic hypothesis. All impairment tests and functional measures chosen must help you refine your diagnosis. These test results should also direct you to the cause(s) of the patient’s functional problems as well. If the tests are chosen effectively, they will help you develop a treatment plan that addresses these pathologies or impairment issues.
For example, in patients with balance or gait dysfunction is it a joint mobility issue, a muscle weakness issue, a peripheral or central vestibular issue? Identifying the specific area is critical to success. If you are working on this patient’s vestibular system and their problem is a lower extremity strength or somatosensory issue you will never help this patient get better.
It’s worth mentioning here that the appropriate selection, administration and interpretation of tests and measures is of paramount importance. First, if you don’t choose the correct test the information you gather is worthless and doesn’t help guide your plan at all.
Secondly you must administer the test correctly according to the established testing guideline. Administering the test incorrectly invalidates the results and again you have worthless information.
As an example: Often people choose the 30 second Sit to Stand test for patients. The test requires the patient to stand from sitting without using their hand. This is because the test assesses lower extremity functional strength. Using their hands to help invalidates the test because you are not isolating the functional testing to the lower extremities. If the patient cannot stand without assistance from their upper extremities, then this is not an appropriate test.
Lastly regarding testing is you must interpret the test results correctly. Knowing when the test is positive vs negative and what that indicates for the patient is crucial in making the correct diagnosis. You may have done the test perfectly but if you don’t correctly utilize the results then that test data is at least worthless and potentially dangerous.
The other point of the examination data is to provide a baseline picture of the patient. As you go forward you be able to use both the impairment and functional testing data as your benchmark for demonstrating progress.
With the history and exam data collected you can develop the treatment plan. It makes great sense to do this in cooperation with the patient so you both are clear on what’s going to happen and where are you will be going with treatment.
The plan should be based on the impairments and functional deficits found through the history and the examination. Be sure you are clear on both the pathologies and the tissue you are addressing in your planned interventions. For example, in the patient who is 3 days post ACL reconstruction, the loss of flexion motion in the knee is not likely due to scar tissue in the knee nor contracture of the quadriceps. You must know the post-op effusion in the joint is the cause of the loss of motion and focus your care there.
There is great potential that your plan may need to consider staging the rehab process. It’s often true you need to address and correct one condition before you can move onto another component. In the above example if you don’t improve the effusion to increase the ROM you will not be able to address the gait and strength issues effectively. As you develop the plan consider what steps you may need to correct and the optimum sequencing of interventions.
As you wrap up the initial evaluation consider two things beyond whether you’ve collected all the information you need.
First, seek to ensure that you’ve created a sense of value for the patient. Patient’s needs to feel their time, money and effort will be well spent. You may have conducted the most awesome initial exam ever but if the patient doesn’t believe the treatment is going to do much to help them then you’ve both wasted your time.
Second, have you given the patient a sense of control over their situation? All patients need to have the feeling they have some ability to control the course of their recovery. A sense of control achieves both buy-in from the patient and eases any anxiety they may have about a loss of control. Both are important for successfully recovery.
One great method often used is to review the following with the patient at the end of the examination:
This works as a summary of the findings, a way to obtain consent from the patient and to be sure you both understand where you are going.
In short, the evaluation not only lets you gather the information you need but helps start the relationship you need for success. Use this initial time to start your patient off in the best way possible.
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