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Guidelines for an Efficient New Patient Headache Evaluation

Date: 08/07/2024
American Headache Society Practice Tips
  1. Delegate as many new patient activities to your staff as possible. For purposes of efficiency, the provider is the most important individual in the patient care process. The provider should only perform core tasks. All non-core functions should be delegated.  At a minimum, delegated tasks include patient check-in; ensuring new patient documents are completed correctly; collection of vital signs; escorting the patient to the exam room; loading the proper new patient note in the computer including demographic information; and performing all non-critical patient education. All clinical information other than the history of present illness (HPI), assessment, and plan should be entered into the electronic record by staff, including vital signs, medication history, past medical history, social history, and review of systems if applicable. Of note, effective January 1, 2021, many elements of the note are no longer needed for billing purposes under medical decision making, such as review of systems. Click here to learn more about guideline changes. A summary table can be found here.
     
  2. Most medical practices use electronic medical health (EMH) records and most of these products can be partially modified. Creating specific templates for new patient, revisit, and procedural visits will save time. Based on both medical needs and insurance documentation requirements, these templates can have comprehensive descriptions of all history, exam, procedural, assessment, and plan elements. The headache patient is an ideal patient for prepopulated exam templates. Most patients have neurologically stable conditions, while the assessment and plan components are the same for almost all headache patients. Unique features for individual patients can either be typed into the note, or preferably, documented using drop-down boxes already in the template (e.g. Imaging > not performed/MRI brain/CT head/without contrast/with contrast/unremarkable/demonstrating non-specific white matter changes).
     
  3. Use an online portal system if compatible with your EMH vendor. A successfully implemented online portal will allow patients to input their insurance and demographic information and allow them to further complete the new patient questions embedded in your new patient (or revisit) template. Most established patients should be able to use a portal system correctly.
     
  4. New patient forms and questionnaires should be mailed to the patient prior to the visit electronically, faxed, or by standard mail. If sent electronically, the patient may be able to utilize your online portal system. The new patient questionnaire should include all the questions you typically ask in a new patient interview (e.g. onset, location, duration, severity, frequency, etc.). Your new patient template should be ordered identically to your new patient questionnaire to facilitate an efficient entering process.
     
  5. Have a designated staff member review the new patient questionnaire paperwork prior to seating a patient in the exam room. It is critical that the new patient questionnaire has been completed and entered into the digital record correctly to maximize the provider’s efficiency. The more comprehensive the new patient questionnaire, the more likely a patient will leave sections blank. The staff member can review all unanswered questions with the patient prior to the patient interview.
     
  6. The medication list is one of the most important documents in a new patient evaluation. The medication list comprises both current and past medications for all conditions. Create a document that will allow patients to see, then underline, all tried medications. Name confusion is common, so providing a written list with both generic and brand names listed will allow the patient to identify their medications correctly. Your written list should include a wide range of categories, including antidepressants, antihypertensives, antiepileptics, sleep medications, allergy medications, and pain medications. Including a failed medication list assists the provider in avoiding repeating medication trials unnecessarily and can demonstrated failed medications to payors for purposes of step-edits or prior authorizations.
     
  7. Consider delegating electronic prescription writing and medication education to staff.
     
  8. Create and provide written handouts to patients at the end of the visit.  Handouts should cover basic topics, such as migraine, migraine aura, medication overuse headache, migraine triggers, lifestyle recommendations, and prescription medications. I prescribe the same twenty medications over 90% of the time. I have created single-page handouts for my most prescribed medications, including dosing schedules and side effects.
     
  9. Always complete your chart note at the time of the visit. One of the greatest inefficiencies, and a chronic issue for many providers, is going back to a chart note to complete documentation. In addition to inefficiency, failure to close a note within a period of time may preclude your ability to bill for the visit due to timely filing deadlines set by payers. Providers should delegate, any remaining chart tasks to a designated staff member if not part of the provider’s core responsibilities. The staff member can review the chart for accuracy and completeness while entering the remaining information from the new patient visit.  An obvious disadvantage to revisiting an incomplete chart note later in the day (or even week) is impaired recollection. A nuanced fact or patient discussion is often forgotten by the end of the day if not entered immediately in the patient note. I routinely acknowledge this issue with the patient with the phrase, “Please give me a few moments to enter this information into the computer.” All patients are aware of the challenges of computer documentation. In particularly complex or sensitive situations, comments will also be read back in front of the patient to confirm accuracy. This allows the patient to participate in the process and become aware of the notation.
     
  10. Being efficient produces rewards. Meaningful and consistent preparation creates multiple benefits: (a) greater work satisfaction, (b) better patient flow, (c) more time to spend on other personal or professional tasks, (d) more time to dedicate to complicated patients without penalty, and (e) potentially greater revenue. Saving even two minutes per patient per day following the above recommendations can yield up to 20-40 minutes of recovered time daily for an average provider (possibly up to 147 hours per year or over 18 workdays).

About the Author

Marshall C. Freeman, MD, FAHS is the Director of the Headache Wellness Center in Greensboro, North Carolina. Dr. Freeman has authored and co-authored numerous articles and textbook chapters on headache medicine and neuromuscular diseases. He lectures throughout the United States as a headache expert. He serves as Chief Medical Officer of Headache Wellness Center Research (HWCR) and as principal investigator on multiple headache studies.