Recognize the benefits of partnership
Forging a partnership with the patient:
- improves the accuracy of information
- eases ongoing communication
- facilitates informed consent
- provides an opportunity for you to educate her.
TABLE 2 When building trust, both patient and physician
are charged with responsibilities
| In regard to … | The patient’s responsibility is to … | The physician’s responsibility is to … |
|---|---|---|
| Gathering an honest and complete medical history | Know and report | Question completely |
| Being adherent to prescribed care | Follow through | Make reasonable demands |
| Making decisions about care | Ask questions and actively participate in choices Make realistic requests | Be knowledgeable about available alternatives Individualize options |
Key concept #3
SHARED RESPONSIBILITY
Patient and physician both have responsibilities that are important to achieving an optimal outcome; so does the hospital (TABLE 2 and TABLE 3). Both patient and physician should practice full disclosure throughout the course of care; this will benefit both of you.4 Here are a few select examples.
TABLE 3 Relative degrees of responsibility for a good outcome
vary across interested parties, but none are exempt
| Area of emphasis | Hospital’s responsibility | Physician’s responsibility | Patient’s responsibility |
|---|---|---|---|
| Creating a positive environment for care | 3+ | 2+ | 1+ |
| Providing clear communication | 3+ | 3+ | 3+ |
| Obtaining informed consent | 3+ | 3+ | 3+ |
| Making reasonable requests | 1+ | 1+ | 3+ |
| Compliance | 3+ | 3+ | 3+ |
| Key to the relative scale: 1+: at the least, minimally responsible; 2+: at the least, somewhat responsible; 3+, responsible to the greatest degree. | |||
The importance of the intake form
At the outset of OB care, in most practices, the patient provides the initial detailed medical history by completing a form in the waiting room. In reviewing and completing this survey with her during the appointment, pay particular attention to those questions for which the response has been left blank.
Patients need to understand that key recommendations about their care, and a proper analysis of their concerns, are based on the information that they provide on this survey. In our practices, we find that patients answer most of these early questions without difficulty—even inquiries of a personal nature, such as the number of prior pregnancies, or drug, alcohol, and smoking habits—as long as they understand why it’s in their best interests for you to have this information. If they leave a question blank and you do not follow up verbally, you may have lost invaluable information that can affect the outcome of her pregnancy.
What should you do when, occasionally, a patient refuses to answer one of your questions? We recommend that you record her refusal on the form itself, where the note remains part of the record.
Keep in mind that all necessary and useful information about a patient may not be available, or may not be appropriate to consider, at the initial prenatal visit. In that case, you have an ongoing opportunity—at subsequent visits during the pregnancy—to develop her full medical profile and algorithm.
The necessity of adherence
It almost goes without saying: To provide the care that our patients need, we sometimes require the unpleasant of them—to undergo evaluations, or testing, or to take medications that may be inconvenient or costly.
After you explain the specific course of care to a patient—whether you’re ordering a test or writing a prescription—your follow-up must include notation in the record of adherence. The fact is that both of you share responsibility for having her understand the importance of adherence to your instructions and the consequences of limited adherence or nonadherence.
Recall one of the lessons from the case that introduced this article: For the patient to make an informed decision about her care, the clinician must have thorough knowledge of 1) the risks and benefits of whatever intervention is being proposed in the particular clinical scenario and 2) the available alternatives. It is key that you communicate your risk-benefit assessment accurately to the patient.
Follow-up
Sometimes, new medical problems arise during subsequent prenatal visits. Follow-up appointments also provide an opportunity for you to expand your attention to problems identified earlier. Regardless of what the patient reported about her history and current health at the initial prenatal visit, listen for her to bring new issues to light for resolution later in the pregnancy that will have an impact on L & D. Again, it goes without saying but needs to be said: The OB clinician needs to have whatever skills are necessary to 1) fully evaluate the progress of a pregnancy and 2) make recommendations for care in light of changes in the status of mother and fetus along the way.
TABLE 4 Examples of the cardinal rule of “Be specific”
when you document care
| Instead of noting … | … Use alternative wording |
|---|---|
| “Mild vaginal bleeding” | “Vaginal bleeding requiring two pads an hour” |
| “Gentle traction” | “The shoulders were rotated before assisting the patient’s expulsive efforts” |
| “Patient refuses…” [or “declines…”] | “Patient voiced the nature of the problem and the alternatives that i have explained to her” |
| “Expedited cesarean section” | “The time from decision to incision was 35 minutes” |