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- Self-Advocacy in Clinic
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- Attending a Doctor’s Appointment
Attending a Doctor’s Appointment
Did you know that your doctor uses a standard workflow for your appointment? Your doctor starts with a greeting followed by data gathering and assessment and ends with your care plan and next steps.
Effectively working with your doctor is easier when you understand the workflow and know when to share information or ask questions. Below are the different stages of the appointment workflow.
There are five stages of a doctor’s appointment:
| Stage | Description |
|---|---|
| 1. Introduction | Goal Setting |
| 2. Data Gathering | History and Physical |
| 3. Assessment | Differential Diagnosis or Treatment Options |
| 4. Discussion and Decision Making | Questions and Shared Decision Making |
| 5. Your Care Plan | Summary and Next Steps |
1. Intro - Goal Setting
Doctors are problem solvers looking for the main problem or ‘chief complaint’ to be addressed in the appointment. If you haven’t shared your goals or helped them identify your chief complaint, your doctor will base the appointment on what they think is essential.
By creating aligned goals, you focus the rest of the appointment on what is most important to you.
Chief Complaint
A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter is usually stated in the patient’s words. The chief complaint is used to describe the reason for the visit and is coded for billing purposes.
Sharing Your Appointment Agenda
Sharing your appointment agenda during the intro stage allows you to communicate your goals, related information, and questions in a concise, easily read format. It jumpstarts your appointment and allows your doctor to ask informed questions that further clarify your situation.
2. Data Gathering - History and Physical
During this stage, your doctor will gather additional data about your issue or chief complaint by asking questions and doing a physical exam. The doctor can start with the data you shared on your appointment agenda. The additional information your doctor gathers helps with their assessment and recommendations.
You want to share a snapshot of your symptoms, your history, including history of this issue, and your family history. When you share how it affects your life, including your work, social life, hobbies, and daily living. This provides more context for your doctor.
Ways to share your symptoms:
- Written descriptions
- Spreadsheets or graphs
- Photos or Videos
- Symptom logs
Physical and History
The doctor will physically examine you based on your chief complaint, your symptoms, and their thoughts on the potential diagnoses or the differential diagnosis.
The patient’s history is an important part of the differential diagnosis. Your history of present illness (HPI) includes the following:
- Previous testing or diagnostics for this issue
- Medications used for this issue including who prescribed it, dosage, and if it worked or not
- Other (related?) diagnoses
- Family history with this issue/disease or related diseases
3. Assessment
Diagnosis
When identifying a new diagnosis, your doctor uses a differential diagnosis which looks at possible conditions based on your symptoms and information. Additional testing may be ordered during the diagnosis process to help rule in or rule out possibilities.
Differential Diagnosis
A differential diagnosis is the process of differentiating between two or more conditions with similar signs or symptoms.
Diagnostic Testing
The doctor may order lab tests or imaging (such as X-rays or ultrasound tests) to help narrow their diagnosis.
Questions You Can Ask about the Diagnostic Process
- What is your differential diagnosis?
- What testing will help you decide?
- Would you be willing to test for _________? To rule it in or rule it out?
- What else could it be?
How You Can Assist with Diagnosis
- Look for doctors with clinical experience, if ultra rare, contact experts and researchers
- Track and share symptoms
- Create and share your history
- Ask questions and share your fears and concerns
Treatment
When a doctor decides on a treatment, they consider the “five rights” of medication use: the right patient, the right drug, the right time, the right dose, and the right route—all of which are generally considered standard for safe medication practices.
Treatment is based on the doctor’s experience with the disease and treatment, scientific evidence, risks, and benefits of the treatment, along with the patient’s preferences and priorities.
Unfortunately, rare diseases like many subsets of eosinophilic disorders can be difficult to treat. With 90% of rare diseases without FDA-indicated treatments, doctors use many off-label medications approved for other reasons. It may take some trial and error, but you can work with your doctor to find the right treatment for you.
Questions to Ask about the Treatment
- What are (other) treatment options?
- Why are you recommending this option?
- What are the risks and benefits?
- What are the possible side effects?
- What are the expected results?
- How much will it cost?
4. Discussion and Decisions
During this stage, the doctor shares their assessment and recommendations. As much as the doctor knows medicine, you are the only one who knows what is best for you, including your preferences, priorities, and values. Shared decision-making allows you and your doctor to work together with all this information to find the best treatment and care plan for you.
You can recognize this stage by listening for your doctor’s explanation and recommended plan. This is the time to ask clarifying questions, questions about additional options, and share what is important to you and why.
Doctors Recommendations
Your doctor will make recommendations based on your chief complaint, symptoms, history, and physical. Recommendations may include further testing, treatment(s), or referrals to other providers.
Your Input, Questions, and Feedback:
Listen to your doctor’s recommendations and ask clarifying questions if necessary. You can share your priorities, preferences, and values that affect the doctor’s recommendations. For example, your doctor recommended a swallowed steroid, but you would like to avoid steroids and start treating your EoE through diet modifications, this is the time to share that with your doctor.
5. Plan and Summary
Your appointment is coming to a close, so it’s important for there to be a clear understanding and agreement about the plan and next steps. One technique you can use is the Teach Back Method.
Understanding the Plan of Care Using the Teach Back Method
The Teach Back Method is a way for you to tell your provider (a doctor, nurse, or other person you see at your health care visit) in your own words what you understand. It is not a test of what you know but a safety check for understanding and agreement.
Three-step Teach Back Method
- The doctor summarizes the plan
- The patient repeats their understanding of the plan
- The doctor provides feedback if the patient’s summary is different than theirs
Your Doctor summarizes the information.
Statements like the following prompt the doctor…
- To clarify, can you summarize the plan?
- Can you walk me through your differential diagnosis?
- Can you summarize the pros and cons of __________?
- I want to make sure I understand. Can you summarize the plan?
You share your understanding.
Statements like the following share your understanding…
- My understanding is ________. Is this correct?
- Let me see if I’m clear on this.
- I want to make sure I understand.
If your understanding is not the same as the doctor’s
When you don’t understand something…
- Your doctor should explain again.
- You can ask questions
- You share your new understanding
Remember this is not about your memory, but how things have been agreed to and understood.
What’s needed at this stage?
- Care plan in alignment with your goals
- Clear understanding and agreement on the plan
- Task list of what needs to be done
- Care plan documented in electronic medical records (EMR)
Is there appropriate follow-up?
- Do you know what to do next?
- Do you know how/where to get your prescription?
- Do you know when to schedule your next appointment?
- Do you know who will help with referrals, etc?
What is in a Plan of Care and Summary
- Summary of the appointment, including the assessment, discussion, and decisions.
- A care plan including a task list and Information about the next steps, including next appointment, referrals, and prescriptions with who, what, and where details.
- Your doctor will record the care plan in your electronic medical records as an appointment note. You should review your appointment notes to validate that the care plan is consistent. Learn more about your rights and accessing your medical notes at Open Notes.
Documenting the Visit
It can be easy to forget some of the information you and your doctor discuss during an appointment, therefore, have a plan to document your visit. Doing so can give you a valuable reference tool if you need to share information with a loved one or specialist, evaluate treatment options, or develop follow-up questions to ask at your next appointment.
Consider these resources to help you document your medical visits:
- My Doctor Appointment Summary Template
- “After Visit Summary” and “Notes”: The ability for patients to access their medical records, including doctors’ notes, varies by jurisdiction and healthcare system. There may be certain conditions or procedures to follow to obtain these records.For example, you may need to request access in writing and may be charged a fee for copying or sending the records. Additionally, there may be exceptions to what parts of the record are accessible, such as notes related to mental health treatment. Ask your healthcare provider or the facility where you received treatment about accessing your medical records and notes.
It’s important to note that state laws vary as to whether or not you may be able to record your doctor’s visit (such as with an app on a mobile device) with the goal of revisiting discussions later. Check local regulations and speak to your provider before recording.
- Individuals’ Right under HIPAA to Access their Health Information
- CDC Steps for Creating and Maintaining a Care Plan
- CDC Complete Care Plan Form
- OpenNotes: How to get the most out of your notes: FAQs for patients
- OpenNotes: How to read an open note
- OpenNotes: How to get the most out of open notes for teenagers
- OpenNotes: How to get the most out of your children’s notes
- How to Check and Fix Medical Records
- The Guide to Getting & Using Your Health Records
Go to After a Doctor’s Appointment ➙
