It’s important to support medical conversations and instructions with clear documentation using straightforward language on well-thought-out forms. Here are a few suggestions to help you get started.
Exchanging health information is a two-way street. On one side, physicians aim to gather pertinent information from patients. On the other side, patients are looking for clear direction from practitioners.
Sometimes, though, medical personnel can lose sight of the fact that patients are coming from an entirely different perspective. This chasm is often evidenced by the use of substandard or outdated forms that are meant to gather and share critical information between all parties.
Unfamiliar terminology, confusing multiple-choice questions, or insensitively worded documents can adversely impact a patient’s comprehension of-and subsequent compliance with-their doctor’s written instructions. Confusing forms can also lead to ambiguous medical histories if patients either don’t understand what’s being asked of them or don’t appreciate the way it’s being asked.
Even something as basic as a lab requisition or online booking form can cause confusion. That’s why it’s important to support medical conversations and instructions with clear documentation using straightforward language on well-thought-out forms.
If you haven’t revised the documents you share with patients for a while, perhaps now is the time to review and update them. Here are a few suggestions to help you get started.
Patient intake forms
The intake form is usually the first touchpoint patients have with your practice. Whether completed in person, online, through an app, or over the phone, it’s vital to keep this document simultaneously simple and comprehensive.
One thing you may need to refresh is the language used for gathering vital statistics. Do your current forms have a respectful and inclusive tone? Are there appropriate gender classifications? The traditional male/female choice is no longer adequate in today’s diverse society, particularly in medicine, where anatomic and cultural clarity are crucial for effective patient care.
Another consideration is the way you collect the names of patients. Many of us prefer to be addressed by a moniker that is different from our legal name. Make sure your intake form provides space for patients to include their favored name, pronoun, and, if they choose, honorific. And remember to ask for the names and numbers of two contacts, just in case an urgent or confusing situation arises and you need to reach someone STAT.
It’s helpful to include details about your booking and cancellation policies, hours of operation, and contact information on the patient intake form. It can also be advantageous to allow room for patients to write down any questions they have about you, your staff, and your practice.
Lab test and radiology forms
To fast or not to fast, that is the question. At least that’s one of the questions. Take a look at the lab, radiology, and other external forms you use on a daily basis. Are the instructions clear? Is there enough information about the location, contact number, and opening hours of the provider? View these forms from a patient’s point of view to see if there are any confusing or vague instructions.
When referring patients to a specialist, it’s thoughtful to write down a few details so they can remember what doctor they’ll be seeing, why they’re being referred, where they’ll be going, when they can expect to hear about an appointment time, and who will contact them to confirm. You may want to consider creating a sheaf of forms solely for this purpose. It could be as small as a prescription pad and may save you and your staff from a lot of questions while saving your patients from a lot of uncertainty.
Procedure explanation forms
Patients need to know exactly what to do in advance of and following all medical procedures. The most efficient and reliable way to ensure this is to provide them with simple, detailed, step-by-step instructions. Use bullet points, outline the chronological stages of the procedure (before/during/after), and add a variety of frequently asked questions to help guarantee patient understanding and compliance. You can also provide links to online resources that accurately depict what will be done. Too many surgeries and procedures are postponed or cancelled simply because of unclear instructions.
Thankfully, I knew what to expect in advance of my recent routine colonoscopy, because if I had relied solely on the information leaflet I’d been given I would have been caught completely off guard. While the 2-page form provided an adequate explanation about dietary restrictions and the procedure itself, there was absolutely no mention of the dramatic consequences that follow ingestion of the preparatory laxative. Out of concern for future patients who may not understand what to expect, I pointed these oversights out to the nurse at my gastroenterologist’s office. I was met with a non-committal, “Hmmm, you’re right.”
I won’t know for another 10 years, but I hope they update that colonoscopy prep form. One way or another, I’m sure it will all come out in the end.
Sue Jacques is a professionalism expert, keynote speaker, consultant, and author who specializes in medical and corporate civility. A former forensic death investigator, Sue now helps people and practices prosper through professionalism. www.SueJacques.com Social: @TheSueJacques