When performing a consultation with a patient — either as a new exam, an update, or an interim daily assessment, there are details you need to cover. We have talked in the past about letting the patient tell their story — let them tell you what is wrong — but ask open ended questions to guide the story to fill in all the blanks. The more complete the interview — the better the story.
I find it easy to forget all the questions — it is easy to get distracted by details or other bits of information, but we need the whole picture. I find it helps to remember the mnemonic OPQRST. I like the notion that OPQRST is the start of a conversation — not the end.
The Alphabet Tool
OPQRST is a useful memory gimmick for learning about your patient's pain complaint. It is a conversation starter between you (the investigator), and the patient (your research subject). Here are some suggestions on how to approach using OPQRST as
an assessment tool:
I have this on my exam forms so it is in my face and reminds me to fill in the blanks. Some patients, especially those with chronic pain complaints, will often "overtell" the story, and try to give you a lot of extraneous information. This does not mean they are malingering. More often than not, they are trying to convince you of the legitimacy of their complaints. Sometimes they will embellish their complaints.
This is understandable: The patient does not feel others believe they have legitimate complaints — nothing broken, no casts or scars — just the vague complaint of pain. These patients have been dealing with their issues for so long that they feel a need to validate.
While this can be viewed as symptom magnification it does not mean the patient is intentionally trying to be misleading — they are legitimately trying to convince you that they have a real pain complaint. Again, listen to the story — the patient will tell you what is going on. Remember OPQRST to make sure you get the complete picture.
The Renovated Story
Also keep your mind open for the "renovated history" — when the patient honestly gives you what they think is a correct history, but it is not. This is typically when a patient has experienced other care or is under other care for a condition and no longer considers it a health issue. A good example is blood pressure — I routinely check and ask about blood pressure as part of my history consult. A patient may have excellent blood pressure and deny any issues, but later in the consult will tell you they are taking Avapro, Coreg or Lopressor. If you ask them why they are taking the medication, they will readily tell you, "It controls my blood pressure."
They assume that since the medicine is in their system and all is well, they no longer have the problem. The patient is legitimately trying to give you what they think is good information, but they don't have a clear understanding of their overall health condition. This requires you to be thorough in your consultation, records review, and patient assessment so that you have a clear and accurate understanding of what the patient's condition and needs are.
Pay attention. Listen to the story. Observe the patient. As providers, we are responsible for collecting and assimilating all of this data to present a clear and accurate clinical profile. Now more than ever we should expect our records will be reviewed by others — insurance adjusters, attorneys and other doctors. The more complete and accurate the records are, the more opportunity you have to validate your treatment and support your care plan.
Think of these notes like a fire extinguisher: you don't want to have to deal with it, but when you need it, you are happy to have it there. During a deposition, an attorney can ask you just about anything about your care of the patient, whether or not you wrote it down. What you "think" or "remember" is not credible – if it is not written down, it is not part of the record!
Keep complete records. If you are ever called upon to justify the care you provided a patient, the notes in your file will be the only tool you have at your disposal. Make sure you take the time to complete your documentation. As I've said before and will say again, it's good practice and good patient care!
Resources
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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