Hi! Today we’re taking a quick break from talking about depression to discuss the “establish care” visit. In my current position, I see a LOT of new patients – both new patients to the practice, as well as those transitioning from another provider to me. I realized pretty early on that I needed to have a standard template to use to organize these visits for myself as well as to ease the charting I’d need to do after the visit. So, after doing some experimenting and review of some of my older “new patient” visits, I developed the template below. I don’t think it’s perfect, but it does help me make sure I touch on all of these topics during our visit as a point of reference.
Now, I obviously modify this template based on what the patient says and the patient characteristic. If, for example, the patient is a 26-year-old male who is a non-smoker, I’ll take out the DEXA scan, AAA screening, annual lung CT, etc. I always leave mammogram and colonoscopy on there, and then record whether or not the patient has a family history of early breast cancer (or breast cancer in males) or early colon cancer; that helps me moving forward as I decide when to start routine screenings.
For example, here is a sample done for a 37-year-old female:
I almost NEVER do a physical on the first visit. There is simply too much information/history to be gathered at that visit, so I treat the “establish care” visit like a first date; I get to know the patient a bit, and we can develop a plan for his or her care moving forward. Sometimes patients will come to me without having had primary care (or sometimes ANY access to health care services) for many years; in that case, we start “chipping away” at the preventative care needs of the patient, with a plan to start with those that are mutually deemed most important and tackling 1 – 2 every visit. For example, I recently had a 72-year-old patient present who hadn’t seen primary care in over 20 years; we started with a pneumonia shot and a referral for a mammogram. The next time she comes back, we’ll address her need for a colonoscopy and zostavax, and so forth. A wise mentor told me once that the beauty of primary care is that you can bring folks back frequently if needed, so there’s no need to solve all of their issues in the first visit. In my experience, the key is addressing your #1 concern (ie. a blood pressure reading that’s through the roof) and the patient’s #1 concern; that way the patient feels heard and valued, but you’re also not throwing away your clinical judgment on key important things. If the patient comes in with 4 or 5 complaints, my nurse knows to let them know that we’ll try to address 2 of them today, so they’ll need to pick their top two and we’ll address the others at a later date. It’s not ideal, but it’s the reality of healthcare today.
So in a nutshell, I see the purpose of the “establish care” visit as a chance to learn about the patient’s relevant history, medications, and allergies, and to develop a plan for the primary care relationship moving forward. Only in very rare circumstances, such as if a patient has literally NO medications or medical problems or complaints, will I do a physical on the first visit; usually, I’ll have the patient get fasting labs drawn, and then return for a physical exam at a later date.
As a final aside, I would highly recommend limiting the number of new patients that can be seen in a day. It can be mentally exhausting and definitely takes a lot longer than a routine follow-up or an acute visit, so make sure you ask to limit that number to save your own sanity. I currently see a maximum of 4 new patients a day, which is about all I can handle.
Is there anything else you cover with patients during an “establish care” visit? Are you in the habit of doing a physical on the first visit, if the patient requests it?