Would your or your team recognize these off-hand remarks that could warrant a change in your notes or clinical procedures?
“My hip hasn’t felt right since that big box fell on me at the store.”
This is your cue to ask if this is work-related or a potential personal injury case in which someone else is liable for the cost of treatment. Is there an attorney involved? Complete the PI or workers’ comp paperwork and let the doctor know.
“I’m so glad that you guys know what you’re doing! Not like all those other doctors.”
Are “all those other doctors” listed on the past history form? If not, talk to the patient and capture the missing data.
“I’m glad you’re on the bus line. I don’t like driving since the accident.”
Bring out your motor vehicle accident paperwork, even if the case appears to be settled and your office isn’t being asked to bill a third party.
“I’m on total disability . . . can the doctor fill out my paperwork?”
Make sure you put together what the doctor may need for additional outcome assessment, and review the patient’s past history for any relevant information.
“The doc’s been adjusting my lower back, should I mention my neck’s been hurting?”
This is a new complaint from an existing patient, and isn’t business as usual. Gather the necessary data before sending the patient back to see the doctor.
[Phone call] “I used to come see the doctor a long time ago. I just want an adjustment.”
This is a reactivating patient. Update their intake paperwork, or start from scratch if it’s been more than three years since the patient was last seen.
Patients don’t always know what’s relevant for the doctor, and certainly not what’s relevant for proper documentation—but you do. Listen carefully for any red flags that tell you this patient and/or this visit isn’t business as usual.