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.
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:
- Onset: "Did your pain start suddenly or gradually get worse and worse?" This is also a chance to ask, "What were you doing when the pain started?"
- Provokes or Palliates: Instead of asking, "What provokes your pain?" use real, casual words. Try, "What makes your pain better or worse?"
- Quality: Asking, "Is your pain sharp or dull?" limits your patient to two choices, when their pain might not be either. Instead ask, "What words would you use to describe your pain?" or "What does your pain feel like?"
- Radiates: This is another chance to use real, conversational words during assessment. Asking, "Does your pain radiate?" sounds silly and pompous to the patient. Instead use this question, "Point to where it hurts the most. Where does your pain go from there?"
- Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10. It is OK to ask what they think is a 10.
- Time: This is a reference to when the pain started or how long ago it started.
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
- Friese G. How to use OPQRST as an assessment tool. EMS1, 19 Mar, 2009.
- Briggs D. Let the Patient Tell Their Story. Dynamic Chiropractic, Oct 2014.
- Briggs D. The Rest of the Patient Story. Acupuncture Today, May 2016.
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.