A re-evaluation – essentially a modified initial evaluation performed at a predetermined time or occasion – has a pivotal role in the continuation of care.
The #1 Reason to Re-Evaluate
The primary reason to perform a re-evaluation is to substantiate your professional judgment regarding continuation of care, modification of treatment or goals. The initial evaluation of the main complaint with the less detailed "progress notes" / "follow-up" notes and re-evaluation create an evolving clinical picture of the patient's status.
Other Reasons to Re-Evaluate
Re-evaluations add structure to documentation. When providing more than a few treatments for a main complaint, it is helpful to organize notes by "courses of treatment." The course of treatment begins with either the initial-evaluation (or re-evaluation), includes a series of treatments and ends with a re-evaluation.
Re-evaluations serve as reference points of a patient's file. It is more convenient to review a patient file by referring to the re-evaluations than each of the individual progress notes (SOAP notes). You can also identify changes in the main complaint over longer, regular periods of time than between individual treatments. You may also use these reference points to illustrate progress to the patient.
Re-evaluations can be used as an informal research tool. You may compare re-evaluations to determine the effectiveness of treatment protocols from one course of treatment to the next in a single patient or between patients.
Re-evaluations set limits for patients. A prospective patient is more amenable to committing time and resources to medical care if they have an approximate time frame of treatment. "I recommend treating you with a course of treatment consisting of acupuncture two times a week for your lower back pain for a two months then re-evaluating your condition and determining the next step" is more enticing than "I recommend treating you with acupuncture twice a week until you feel better."
Re-evaluations can be used as a review for the patient. The re-evaluation can be used as a time to review the patient's progress with them and make suggestions regarding any lifestyle modifications they have made, such as changing diet, exercise, sources of distress, etc.
Re-evaluations may save time over the course of treatment. Summarizing progress and suggesting or modifying lifestyle suggestions for the re-evaluation may save time from the typical visits with treatment.
More than "Treat as is"
When considering the current status ascertained from the re-evaluation along with previous re-evaluations and the initial evaluation, you are able to make an informed decision of how to proceed with care. Aside from treating or not treating, you have the option to:
When to Re-Evaluate
Re-evaluation performed according to the treatment plan. As part of the initial-evaluation, you may have determined a specific time or number of treatments to re-evaluate the main complaint. This duration may vary depending on office policy or main complaint.
Re-evaluation performed when significantly changing the treatment mid-course. You may not feel satisfied with the treatment protocol established or patient progress and not want to wait for the scheduled re-evaluation.
Re-evaluation performed when there is a change of main complaint. Occasionally, the patient wishes to change their main complaint. You might consider this type of re-evaluation "closing" the course of treatment. Including the patient's reason for concluding the course documents that is the choice of the patient and not necessarily that of the practitioner.
Re-evaluation performed as part of discharging the patient procedure. If the patient seeks to terminate care because they are satisfied with progress or other reasons, then a re-evaluation documents the ending status of the patient's main complaint.
A Pivotal Point of Care
Although the main reason to re-evaluate a patient's main complaint is to determine how to proceed with treatment, re-evaluation may have a role in other aspects of the clinical setting. The re-evaluation may have a place during the consultation of the prospective patient, when reviewing a file and/or when developing treatment protocols. It has the potential to contribute to gaining patients, saving time and improving treatment. It is more than just a modified initial-evaluation; it serves as a pivotal point of patient care.
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