The secret sauce......

Image: Theo Crazzolara (Via Unsplash)

Reviewing your patients

I remember working in a clinic and seeing a patient who had been attending for some years. At some point in the treatment process I realised that I didn’t really know why she was attending. There were no clear reasons spelt out in the clinical notes, and I was slightly apprehensive to ask the patient that question, for fear of somehow upsetting the status quo and finding that she didn’t want to come in any more……

I realised that I had no clear agenda, and I certainly wasn’t aware of the patient’ agenda (or even if they had one).

So I resolved to review that patient the next time they came in….

My model for the process looked a bit like this:

Patients Agenda + My agenda = Mutual agenda (aka Maintenance Plan)

If we accept that some patients may benefit from preventative chiropractic care (we’ve touched on this already), what issues should we be aware of with those patients, and how would we address those issues?

Make a list of issues that you think would form part of the chiropractors agenda and write down the techniques that we will use to assess them:

For example: 
Issue: How do I know what medication is the patient currently on? 

Technique to find out: Ask the patient.

Write your list down!

We want to be aware of everything of course We have to remind ourselves about the patient issues because we tend to forget….!

Checklist

Current mechanical symptoms.  Ask or written questionnaire
Medical situation.     Ask or written questionnaire
Current medication.    Ask or written questionnaire
Previous medical history refresh.  Ask/read notes (both?)

 Familial Hx, children, occupation
Levels of physical activity/fitness Ask
Diet.      Ask/questionnaire
Stress/Happiness levels.   Ask/questionnaire
Posture.     Visual assessment/Myography/Posture screens etc
Overall mobility.     Observe walk, squat, arm elevation.

Orthopaedic testing
Spinal function.     Palpation
Neurological assessment.  Reflexes, strength sensation tests, Cranial nerve tests?….
Vascular situation BP measurement, pulse assessment, carotid auscultation, VBAI tests
Medical assessment: Abdominal palpation, urinalysis, chest auscultation
Bone strength: Height measurement, or DEXA scan, Medication history
Weight/BMI Weigh patient
Diabetic? Urinary tract status.  Urinalysis
(this is not an exhaustive list!

These issues should be reviewed periodically!

I remember once doing an observation of a colleague in another clinic. Back in those days his clinical notes were all in paper files. He had a thick pile of these files on his desk. I asked him: ‘How many of these patients have had their BP measured in the past 12 months’? ‘None, probably’, was his reply…….

From the UK General Chiropractic Council Code of Practice (2025):

Section C: Standards:

C4: You must develop, apply and document a plan of care in full agreement with the patient. You must check the effectiveness of the care and keep the plan of care under review. A more formal reassessment of the effectiveness of the plan of care must be undertaken at intervals that suit the patient and their needs. All subsequent modifications to the plan of care must be discussed and agreed with the patient and properly documented.

Section E3

You must check with the patient that they continue to give their consent to assessments and care.

(Highlight and underlining are mine)

I  decided that any patient who is having regular care in my practice should have a formal review periodically.

But how, exactly do we do that?

If you have never reviewed patients in your clinic, how do you introduce the review concept? 

Discuss the idea with your staff before you do this, so that they know what you are doing and why you are doing it

We are obviously going to take a little longer with a patient when we do a review, so either:

• Review a patient when you have a naturally occurring longer slot in your diary and have time to do one, or:
• When you have seen a patient, ask you receptionist to make their next appointment a double slot when they go out to make their next appointment .
• Don’t review all of your patients at once – spread the reviews throughout the year

Starting the review process (detail) – the ‘asking’ bit

When you first see the patient, do what you usually do…. Which is probably to ask them how they are….and let them tell you.

Then say to them that you would ‘I would like to review your case, if that’s OK, just to make sure I’m completely up to date with your health situation’

Then do all the asking that you need to do (having first looked through their notes so that you don’t appear too surprised when they tell you about their knee replacement 5 yrs ago!)

Check list:

• Current chiropractic situation
• Medical situation
• Medication
• Previous/current illnesses
• Previous operations
• Previous fractures and accidents
• Familial medical history
• Stress levels
• Levels of physical activity (cont overleaf….)
• Diet
• Job
• Domestic situation

Congratulations, by asking about everything, you’ve started to consider patients in a holistic manner again!

Do a brief postural/global orthopaedic assessment of your patient

Points to consider

• Foot pronation
• Knee torsion
• Hips and pelvis level?
• Shoulders level
• Internal/external arm rotation
• Head tilt
• Look at them from the side too – abdominal tone?
• Look at them from the front
• Any obvious cranial distortion
• Get them to squat down and stand up again (how are their knees?
• Tip toe and heel walk
• Touch toes
• Elevate arms/bend elbows/scratch back

Bear in mind that in practice you will be doing this with a patient that you already know, so you should be able to do it pretty quickly!
This screening should be applicable whatever technique/approach you use.
Make some notes.....

Safety section 

Think about a nightmare scenario that you encountered at some stage in your career with a maintenance patient. If you have not had any problems, make up an imaginary nightmare scenario that you dread having happen to you.

Write down your worst scenarios....

Are there any safety checks that you could do that might alert you to the possibility of any of these potential problems?

Write them down......

I'm sure that your imagination is vivid enough, but in case it isn't, here are some possible nightmare scenarios (amongst others):

• Stroke
• Heart attack
• Cord compression
• Arterial dissection
• Aneurysm rupture
• Osteoporotic fracture

Safety tests/checks that we therefore consider may be useful:

• Reviewing Medical History
• BP
• VBAI
• Pulse assessment
• Abdominal palpation
• Urinalysis
• Measure height. Useful when thinking about osteoporosis. Bone density testing (DEXA) scan
• Neurological screening – reflexes at least, ideally strength and screening for pathological reflexes (brisk reflexes, inverted reflexes, clonus, Babinski etc)

Pearl:

• If you review your patients holistically, and address some of the safety issues head-on, it is possible that you might be able to prevent some of the above scenarios and add years to a patient’s life. Isn’t this what healthcare is all about?

The rest of the review:

Will consist of:

Spinal palpation

Specific technique tests

Orthopaedic tests

Neurological examination – reflexes strength, sensation

Physical examination –abdominal palpation/(+heart/lung assessment?) skin assessment? Urinalysis?

Weighing the patient (this gives a great opportunity to address the issues of diet and alcohol.

Measuring their height

Having done your assessment, tell the patient how you see their situation, and what your agenda is. Essentially, you will be explaining why you are doing what you already do.

The patient’s agenda – goal setting (look back at the previous discussion about goal setting)

Think about any chiropractic treatment that you have had in the past.... What do you think that chiropractic treatment does for you? What would you like it to do for you in the future – write it down......

I usually ask patients ‘what do you feel chiropractic does for you?’ in order that I can get a feel of why they come and see me. For some people this may be so that they can achieve something specific that they currently are unable to do, but for more patients it is to continue to be able to do what they already do, and for another large sub-group of patients it is more vague than that: ‘mobility’, ‘keep me in shape’, ‘keep me going’, ‘make sure that things are being monitored’. This is hugely helpful for me to know and allows me to try and see the situation from the patient’s perspective and then use the appropriate language when talking with them.

Is there anything else that they would like to change about their health (or indeed about their life) in the next year that they would like to discuss with you? (weight loss, physical fitness etc)

Ideally, goals should be ‘SMART’: Specific, Measurable, Achievable, Realistic, and Timescaled.

An example: To turn a focus area of ‘I want to get fitter by swimming regularly’ into a goal you might write:

‘I will swim on a Mon, Wed and Fri lunchtime (S). I will do 30 lengths of the pool (M). I know that I can do 30 lengths in 45 mins and that this will still give me time to have a sandwich (A). I have done this in the past and I believe that I can do it again (R). I will start the week after next (T).

(Much of the above can be done while treating the patient)

Merging their agenda and mine......

You need to have a form!

• For safety
• So that the patient and the chiropractor can sign it
• To refer to next year (we can scan it into our records)
• So that the patient can take it away

GCC Code of Practice (2025)

A1: You must show respect, compassion and care for your patients by listening to them and acknowledging their views and decisions. You must not put any pressure on a patient to accept your advice. 

Doing a review like this helps the patient to understand WHY we are planning to see them this year, and it helps us to understand what they hope to achieve with their health over the next year

Here is an example of a review form. Feel free to copy it or make your own version.

Making the bookings

In my practice it is policy that all patients who have preventative care have an annual review.

In order for the review to occur (I allow a double appointment for a review) it has to be pre-booked otherwise it simply does not happen due to a lack of time.

I tell this to my patients when I have reviewed them for the first time and ask that they make their appointments for the year ahead, including their review appointment in 12 months time, otherwise the review does not happen.

Of course, patients do not know what they are doing for the 12 months ahead. I tell them not to worry, book the appointments anyway, and just shift any appointments that clash with holidays etc. The further ahead they book, the more likely they are to get times and days that suit them.

I then go to the front desk and tell my receptionist what bookings to make over the next year. Do be aware that when you start to introduce this approach to patient management into a clinic that has never booked more than one treatment ahead, your receptionists will subconsciously sabotage booking the care plan ahead! Once they have been doing it for a while, they too will realise that it makes lots of sense, and is in the patients’ best interests.

Advantages to clinician and chiropractor to reviewing and pre-booking:

• Your patient knows what you are expecting
  
• If a patient cannot make it on the day, you probably will see them again
  
• Your diary fills up ahead, and you become much less new patient dependent. 
• Less workload for the reception team on subsequent visits
• Your associate will then see more of the new patients, because you’ll be busier. They will then be busier and will not be able to see many new patients and you’ll need a second associate…... All without needing to see more new patients!

Pearls:

• You need to have an agenda – so you need to look at the patient afresh by reviewing them.

• You need to remind yourself what the agenda is, so you need to do it periodically, at least once per year.

• Find out what the patient’s agenda is – ask them!

• You should then be able to come up with a rational plan about what you are going to do for them (treatment) and what they are going to do for themselves

• Doing this process annually with your long-term patients will enable you to continue to see them with a fresh pair of eyes. You and they will both understand why you have this on-going working relationship

• Its way safer!

• The GCC say you should be doing this anyway

• You commit to the plan by having the patient book up their treatments ahead in the diary, with another review at the end of the planned treatment time (a year later).

Quote from a chiropractor who had just done a mentoring session about this very topic:

‘I booked in my first patient for a course of care for the year with quarterly visits today. I don't know what I was worried about..... he was dead chuffed to find out that we could try to manage his underlying problem!’

Well done on getting through this material!

One day all chiropractors will be doing this! You’re already ahead!

Let me know how you got on. Was it helpful? Any suggestions to improve the programme? email me: andy@kaizendc.com

Thanks!

Here are the links to all the seven sections again: 

Section One: 'Job Centre'

Section Two: '...but why'?

Section Three: 'What's the Plan'?

Section Four: 'Goal setting'

Section Five: 'OMG, he booked more than one appointment'!

Section Six: 'Discharge, or Maintenance?'

Section Seven: 'The Secret Sauce'

If you feel that you have benefitted from this free programme, can I ask you to consider making a donation to 'Shelter', a charity that supports the homeless? Please consider giving the equivalent of the cost of one treatment session at your clinic (currently averaging £50 in the UK):