This blog post explains:
What a Visit to Your Doctor is All About.
The Top 3 Things to Learn From Your Doctor Visit.
- Using S-O-A-P at Your Doctor Visit.
Doctor Visit Basics
You are in the examination room waiting for the doctor. You want relief from the pain. Maybe you are worried about getting back to work, or upcoming surgery, or just anxious that your life is now upside down due to an injury.
In every injury case, you and your doctor need to discuss eight (8) major topics: (1) what are your symptoms, (2) where are your symptoms, (3) when did your symptoms start, (4) exam and test results, (5) diagnosis, (6) treatment, (7) prognosis and (8) medical causation.
Symptoms are things that you, the patient, feel and observe, such as pain, swelling, headache, tingling, numbness, sleep disturbance, extremity pain, and the like.
Diagnosis is the "medical term" the doctor uses to describe your symptoms.
Prognosis is the "medical forecast" your doctor makes about how your symptoms will increase or decrease over time, and what treatment you may need in the future, such as surgery or repeat testing.
Medical causation is the "medical connection" between your diagnosis, prognosis, and the mechanism of injury that caused your symptoms in the first place.
To make a personal injury case in Kentucky or Tennessee, your doctor must express a medical opinion based on "reasonable medical probability." Note the word "probability." Probability means more likely than not. Medical opinions expressed in terms of possibility are generally not admissible in Court, because anything is possible. As your attorney, one of my key functions is to help you understand how the symptoms, diagnosis, prognosis, and medical causation combine to build your case. Once you and I have this information, my job is to ask your doctor for honest and objective opinions that will provide the evidence I need to resolve your case.
The Big Three Questions to Consider With Every Doctor Visit
From the beginning of your case, here are the top three (3) things at the top of every visit you have with your doctor:
- What is my DIAGNOSIS?
- What is my PROGNOSIS?
- What is the CONNECTION between the diagnosis and the incident that injured me?
Assure your doctor that you want to get back to the state of health you enjoyed before you were injured. Listen to your doctor and follow advice. If you cannot follow advice, talk to your doctor. If you cannot trust your doctor, then consider another doctor. You have to build a relationship that is real and constructive.
You may not get answers to these top three questions on your first visit. It may take time. But be persistent. As you get answers to these questions, pass that information on to Burman Law. We look at this immediately and make decisions about your case based on what you tell us. And of course, contact us if your doctor tells you something that raises a concern about your case, or if your doctor seems unable to answer these key questions. We have years of experience to help cut through the problem.
To help you understand in more depth what a doctor visit is all about, read the next section about how to use S-O-A-P.
Using S-O-A-P at Your Doctor Visit
Let me explain. The doctor walks into the examination room. There is precious little time with the doctor. You need information. The doctor needs information. How do you help the doctor help you? Here is how you do it. You add S-O-A-P!
S – O – A – P is a memory trick to help you remember. It stands for: Subjective - Objective - Assessment - Treatment.
“S” stands for SUBJECTIVE. When your doctor comes into the room, the doctor usually asks “what hurts?” Help your doctor understand what has changed about your injury since the last visit. Discuss with your doctor:
- Onset. Tell the doctor about the injury event that caused your pain in the first place.
- Location. Tell the doctor where your pain is located. Be specific.
- Duration. How long have you felt this pain?
- Character. Is the pain dull, sharp, achy, etc.?
- Alleviating/Aggravating Factors. What lessens the pain? What increases it?
- Radiation. Does the pain travel?
- Temporal Pattern. Is your pain different at different times of the day or night?
- Symptoms Associated. Does certain pain seem to cause other pain or symptoms?
What we are talking about here are subjective observations. These are symptoms the patient verbally expresses or has stated to be significant. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes.
“O” stands for OBJECTIVE. Your doctor will run studies and tests that are based on objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests. Ask your doctor what these objective tests reveal about your injury. Objective tests include:
- Vital Signs.
- Findings from Physical Examinations.
- Results from Lab Tests.
“A” stands for ASSESSMENT. Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases, the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.
“P” stands for PLAN. The last part of S – O – A – P is the health care provider's plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions, and follow-up directions for the patient.
AFTER YOUR VISIT, WRITE DOWN WHAT YOUR DOCTOR TOLD YOU AND CONTACT BURMAN LAW WITH THIS VITAL INFORMATION.
REMEMBER TO FORWARD ALL WORK EXCUSES TO BURMAN LAW.
The Burman Law Client Portal is a great place to update Burman Law on your doctor visit and file your work excuse.
"And as always, feel free to contact me anytime you have questions or concerns." Mike Burman