The Annual Physical
Sometimes called the “wellness physical”, this encounter is a time to focus on the big picture. It is a time to step back and consider the patient as a whole. Chronic medical problems are address. Medications are review. Screening for primary prevention is complete. It does not take a very complex patient for the to-do list to mount up rapidly. SOAP documentation for these encounters can be a cumbersome prospect unto itself. In this article, we will discuss some of the things that go into making a good annual physical. We will also discuss how to make the annual physical efficient for the provider and the patient.
If you are a provider who does annual physicals, you have probably done a lot of them. You probably have a pretty good routine by now. That’s great! That means you have form habits that ensure nothing is missed. We have compiled a list of habits and routines that providers use to maximize the annual physical. Check it out:
Happy Birthday!
Many providers plan the annual physical during the patient’s birth month. This is somewhat befitting of an encounter that is design to reflecting on the patient’s overall condition. This helps patients remember when their last annual physical was and when their next one will be. It is helpful for the providers planning purposes as well.
Set an agenda
Many providers elect to only tackle the annual physical during this appointment time slot. This is especially important in patients with complex and ongoing medical problems. Other issues can distract from primary prevention of new issues. Setting an agenda helps to minimize these distractions. Setting an agenda allows patients to verbalize their needs and for the provider to arrange a follow-up plan for them. Some providers elect to refill medications for chronic medical problems during these appointment times. This at least keeps patients current until another appointment can be made.
Have handouts ready
A frequently heard saying in the medical community is “if it wasn’t documented, it never happened.” You can go a step further and say that “if it wasn’t written down for the patient, it wasn’t discussed.” A lot of counseling typically occurs during the annual physical. This is a prime opportunity to provide the patient with helpful information. Some information can include tips on weight loss, exercise, diet and smoking cessation. Providing patients with handouts on this information will save time and provide the patient something to reference in the future.
Get Labs done ahead of time
When patients come in for their annual physical, having their labs done ahead of time allows for more to be accomplished during the appointment. Providers who do this can counsel patients regarding the lab findings during the appointment. Additionally, it can save the patient a follow-up phone call and/or visit.
Use a template
This appointment is fairly routine. Yet, the recommendations for primary and secondary screening are numerous, complex, and ever-changing. SOAPassist has a curated medical form template that reflects the practice patterns and many current guidelines for these screenings. Additionally, patients with other complex issues require secondary screening. Templates for issues that require secondary screening items can be easily integrated into the annual physical template with the SOAP note generator. The result is a custom SOAP note template create instantly and easily.
Whatever your method is, it’s good to have a plan to maximize the annual physical encounter. Each provider/practice/patient is different. We hope that you can take advantage of some of the tips we have discussed. To that end, SOAPassist allows you to save the annual physical template, and any other template, as your own. This allows you to modify it to be consistent with your practice patterns. SOAPassist is also a template-sharing platform, so feel free to share your annual physical template with your colleagues through SOAPassist.