International Journal of Current Medical Science and Dental Research (IJCMSDR) Volume 1 Issue 1 ǁ May-June 2019 ǁ PP 23-27 ISSN: 2581-866X || www.ijcmsdr.com
The Patient Check List 1,
Zaid Mera,2,Manal Al-kaiem, 1, 2,
MSC Imperial College of London, PhD University of Buckingham
I.
INTRODUCTION:
In our everyday practice, when the patient attends his outpatient appointment, he/she expects a full perfect session of consultation with the expert. So, a good preparation from both parties promotes a better quality of the consultation and minimises the risk of missing any information.It is estimated that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder of investigation [1].Despite this might be debatable and differs from case to case, the patient presenting history remains the essential aspect of clinical practice and appropriate history taking can easily lead the clinician to make a correct diagnosis of the health problem in many cases.So that, the patient’s preparation before the consultation is highly recommended, and importantly, we need to focus on the records before reviewing the patient.
II.
DISCUSSION
When the patient comes to see the hospital consultant, he or she assumes that the doctor has a good knowledge about their medical problems, even if it’s their first consultation with that consultant. This is due to the fact that they might already have discussed their health issue with their general practitioner doctor, or they suppose that a consultant has excess to all of their previous health records, but unfortunately despite the GP should have provided all patients records to the hospital, this may not be the case, especially when there is an urgent referral[2]. Obtaining a comprehensive medical history is certainly the most important component of doctor-patient communication which is crucial to reach an accurate diagnosis, prognosis, and treatment plan. Many barriers can be recognized during a history taking like: 1. Patients may demonstrate inconsistency while they recollect the events, this is either due to difficulties in verbal communication, comprehension, recall, and evaluation [3,4,5] 2. Fear or embarrassment during the face-to-face meeting can have a great impact on the patients’ responds and may mislead the clinician. [6] 3. Physicians commonly interrupt patients leading to an inadequate history with some lost details. 4. Gender, race and culture can lead to physician bias due to inappropriate adaptation in questions which results in extra barrier to obtaining a more precise clinical history. [3.4.5] The reasons behind these can be categorised into hospital factors and patient factors. Hospital Factors: The increasing pressure due to the growing number of patients booked in each consultant-led clinic affects inversely on the clinical practice and certainly will affect the general performance of the clinicians. The consultants or their team will need to allocate a specific time for each patient’s visit trying not to exceed that limit in order not to affect the pace of the work.This might force the team to be in rush during the consultation, therefore increases the risk of missing some information and subsequently affect the patients’ care and their satisfaction.The patient referral under certain protocols is another reason of incomplete or inappropriate clinical summery. Some of the clinical presentations which are suspicious of malignancy (categorise in the referral under ‘Urgent’ pathway) for example the patients who had a testicular lump or high PSA results during a routine check or painless visible haematuria. The NICE Guidelines are guiding the GPs in referring these patients under these circumstances to the specialist opinion through an online referral system which might be sometimes achieved only by ticking the relevant box without going through the details of the problem or recording the full clinical story of the current presentation. These patients’ consultations might take longer than expected
Patients factors: Firstly, there is an obvious variation in the way the patients may present to their outpatient appointment. Some of them are very quiet and answer the direct questions only, they don’t say if you don’t ask.
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The Patient Check List. On the other side, there are some patients who are over-confident. They come to their appointments fully overloaded with lots of information from different recourses, for example, the internet or friends to address their anxiety.It’s not uncommon for some patients to present with anger due to the long waiting for their appointment and this will inversely affect their ability to tell a good story about their problem.Although asking an open question rather than a leading one is usually recommended, but this is not always the case. This may be challenging and making addressing the patient concern is quite difficult in a limited-time clinic. An example of that when the historian is a chatty patient who struggles to give clear and brief history [7]. Illustrating this point, a recent prospective comparative study found that non-medical research assistants with no time constraints obtained more accurate medical histories than busy emergency department (ED) physicians [16].In addition to the previously mentioned points, the difficulty in getting a reliable history from the patients may arise from abnormalities in their mental state or the sharpness of their memory. They might use their carers or relatives to tell the story properly but it’s challenging when they come to the clinic on their own with no one accompanied them to support.Nevertheless, the language barrier is another problem affecting the communication between the patients and their doctor, patients may find it difficult to tell their stories thoroughly as if they can do it in their own words. At the other hand, they may not understand fully their doctor’s plan or advice about their management but they find it embarrassing to clarify especially if they need to ask for clarification more than one time.As a result, the traditional method of history taking may involve serious problems for the physician which is amplified in an emergency setting. Secondly, in spite of the ongoing investment from the NHS, the waiting lists are high with over 1.5 million outpatient appointments occurring each year. Although the National Health Service is one of the best organizations of the twentieth century, while we move into the twenty-first century both expectations and demands are increasing. The people experience with the NHS has become more important, and one of the major sources of patient dissatisfaction in healthcare is the waiting time which correlates negatively with patients’ experience [10]. Bleustein et al found that every aspect of the patient experience correlated negatively with longer wait times. A longer waiting time can negatively influence the postoperative satisfaction, as well as patient-related outcome [8,9]. Longer clinic time is another problem facing the health care system in the UK. With the current pressure on the NHS, consultations allocate about 10-15 minutes for a full history, examination, and discussion, but this certainly takes longer if the patient is not well prepared to this clinic [11]. So, it is really important to use the clinic time efficiently and appropriately to get as much as possible information from the patient visit. The waiting time for the patients to have their first outpatient’s appointments have risen dramatically within the last few years and according to a data from The Department of Health, Social Services and Public Safety (DHSSPS) these patients’ numbers have been increased in Northern Ireland reached unprecedented levels in December 2015 when around 235,000 patients were waiting. It is more than three times the number of those patients were waiting for the first appointment in 2009[12]. In the meantime, patients have the right to a maximum of 18 weeks waiting time from the day of referral to the consultant-led treatment. In addition, where cancer is suspected. they have the right to be seen by a cancer specialist within a maximum period of two weeks from the time of GP urgent referral [11]. On the other hand, outpatient non-attendance (patients who have a scheduled outpatient appointment, do not cancel but do not attend for care at the date, time and location) is another problem which reduces clinic productivity and efficiency, delays access to care for other patients and increases the financial burden on the health systems. During 2005, missed appointments cost the United Kingdom National Health Service an estimated $1.54 billion [17].Lots of ideas and articles published to address the non-attendance issue and a systematic review (done between November 1999–November 2009) compared the telephone, mail, text/short message service, electronic mail and open-access scheduling to decide which is best at reducing outpatient nonattendance and providing net financial benefit. That showed a telephone, mail and text/short message services interventions all improved attendance modestly but at varying costs. The use of appointment reminders—letters and telephone calls—reduced non-attendance from 24% to 14%17 [13] and we expect the (The Patient Check List) to help in the same way.Few data are available regarding electronic mail reminders which may play an important role in reducing the non-attendance, yet no systematic review has been published to allow a critical comparison of the all available communication methods [14]. The Innovation:As a solution, electronics self-administered clinical history and checklist send to the patient before the outpatient appointment may improve the quality of the patient care thereby: 1. Preparing the patient for the real patient-physician interaction.
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The Patient Check List. 2. 3. 4. 5.
Reducing the variability in questions asked by physicians. Allowing for a more completed problem presentation. Improving the patient-clinician communication. Set as a reminder for the patient to reduce the DNA number.
Creating a patient “check list” is the way forward to improve the quality of the outpatient clinic in meeting with a good clinical practice.It can be done by emailing a questionnaire to the patient who has an outpatient appointment, it needs to be filled in before he comes to the clinic. A copy of the completed form will be sent back electronically to the clinic and be with the consultant before their expected meeting.Each specialty can produce their own questionnaire according to the common clinical presentations in this particular specialty. For example, if the patient referred because of their lower limb claudication, the questionnaire should be prepared by the vascular surgical department and it will ask the patients to demonstrate the problem in their own way guided by the questions and limited with a number of words. This should be in an interactive manner. In other words, when the patient writes it will start to ask some relevant questions like the claudication distance, the nature of the pain, the severity score, relieving and aggravating factors, etc. Consequently, this will encourage the patient to tell the story in an organised way using a simple language, away from the stress of the clinic visit.Those with poor memory can answer the questions from the rest of their homes using all of the required assistance of their careers, relatives, or even using their own notes or diaries which might be unpractical if they do the same during the clinic. In addition, as the UK is a multicultural society, Many Patients are not good English speaker. As a result, it might be much easier for them to use the online translation service or get the help from their relatives or friends by explaining the meaning of the medical questions. This will definitely ensure a better-quality answer.At the end of the Check List, there will be a section asking the patient to add any question they need to discuss and get an answer from their consultant during the clinic visit. After filling all of the relevant parts of the check list, the patient will be asked to submit the data. A copy of the filled Patient Check List will be sent to the targeted clinic and can be saved with the patient records. It has to be easily accessible by the team looking after the patient at the clinic.At the same time, another copy will be emailed to the patient and give him the option to print it off himself.Each check list can automatically create clear instructions to the patient about how to get to the clinic and of what he/she expected to do before that day in terms of preparation.It can be developed to create instructions for patients awaiting diagnostic invasive or non-invasive procedures as if whether they need to fast or not, the time of the last allowed meal, the regular medications and what needs to be stopped or to continue on before they come for their appointment.
III.
THE BENEFITS
The Patients Check List (PCL) will enhance the patients’ contribution to their own health problems and will raise their awareness about the risk factors and their role in the treatment of their illness. It will give more confidence to the patients with poor memory to tell their clinician the story of their problem and then write down the outcome of the clinic. The impact of the language barrier will be minimised as patients will be more confident that their clinician had their story properly and clearly. Reviewing the (PCL) in few seconds in advance will give the clinical practitioner a broader idea about the patient, summarise their complaint and help in meeting the patient’s expectation from the visit. It will help in applying a better use of the recourses especially the time factor which can positively increase the number of patients needed to be seen in every clinic within the same period of time. While the Patient Check List creates a clear summery of instructions to the patient, the risk of having some procedures cancelled because of the patient’s misunderstanding of what he supposed to do before his procedure. For example, the patients may assume that all of the regular medications need to be stopped before any diagnostic procedure. While it happens frequently to get these procedures cancelled like a biopsy procedure or diagnostic endoscopy because of a high blood sugar or blood pressure as a subsequent result of missing a dose or two from the regular medication. The recorded Patient Check List can be used as a source of data for the medico-legal issues. Allocated two or three lines in the Patient Check List can be used at the end of the consultation, to write down the outcome and whether there will be any further investigations or follow-up appointments. It can be used as a reminder to reduce the probability of non-attendance, as a tool to predict the potentially non-attendee patients, those who fail to fill in their PCL can be contacted before the day of the clinic to
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The Patient Check List. make sure they know about their appointment, confirming their willingness to attend or find out a reason for not filling the form or the possibility non-attendance. This will help the decrease the those who don’t attend.
Work plan: The use of the Patient Check List can start as a pilot study in one of the surgical departments, 1. The chosen department will need to set up its own lists of some of the most common clinical presentations and making the history taking sheet of each presentation in a flow chart. 2. Discuss with and getting an advice from the IT department. 3. Converting the flow chart into an interactive questionnaire and generating a software to support them. 4. Train the administrative team about how to use the new PCL then they can help the patients to use them. 5. Contact every patient referred to the specialty with an email giving them an access and explain to them the need to complete the questionnaire before their upcoming clinic appointment. Alternatively, this can be done by the GP administration team after getting the reason for the referral from the doctor, they email the patients with the questionnaire and ask them to complete it. 6. After filling in the required fields and submitting the questionnaire, an automatic email will be sent to a generic email address of the clinic. 7. Print off the questionnaire or forward it by email to the consultant of the clinic. 8. We will ask the patients and the clinical practitioners to give their feedback. 9. We will audit the results in few months to ensure the cost-effectiveness of the project. 10. We can use a paper questionnaire for the pilot study to get initial results from our project. Follow up patient appointment:Those coming for a follow up can have a mini PCL or follow up PCL. It will ask the common questions for those on surveillance or whom already started a medical treatment before they come for their routine follow up appointment. These questions will be about any changes since the last clinic, any new concerns, side effects and queries for their consultants. Limitations: The lack of similar projects makes it hard to presume the exact outcome in term of the cost effectiveness. Implementing the Patient Check List may face some resistance from some service providers or may be from the patients themselves, so efficient education and raise the public awareness about the new practice is essential.A collaboration between the clinical specialities with the IT department as well as the GP practices is a corner stone for a successful application of the Check List.
IV.
CONCLUSION:
The patient checklist is a simple innovation which can positively change our current practice. It supposed to play an important role in reducing the clinic waiting time, a non-attendance rate and improving clinical history taking. It is a tool for encouraging the patients to write their own health stories. It consists of an electronic questionnaire which can be emailed to the patient prior to the expected date of the clinic. It differs from one department to the other depending on patients’ chief complaints. The work plan includes generating the checklist, developing a software to support the interactive nature of the PCL and training of the administrative staffs. The application of the PCL can start as a pilot study in one chosen department. After few months, we can measure its effectiveness as well as the patients’ satisfaction. The PCL can be used for variable purposes like preoperative assessment and follow up appointments (Follow Up PCL) which targets the patients who already have been seen in the clinic and need another follow-up appointment to check their response to the management. Further improvement in the conduction of the project could be achieved by adding simple practical features.
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