Instead of hand-written patient charts, medical information is now managed almost solely through an electronic health record (EHR). This means that all information about a patient’s care, both within and outside of the physician’s office, must be communicated and stored electronically. This provides a challenge for community-based exercise professionals who deliver fitness services outside of the health system. Any written notes or assessment documentation will need to be scanned into the EHR by a member of the office staff to be part of the patient’s record.
You have several communication goals:
- If needed, ensure that you have medical clearance and individualized guidelines from the health care provider;
- Provide information to the clinician from the patient’s initial assessment and send periodic progress notes (know that the patient can access their medical records so keep that in mind when offering opinions or making subjective observations about a client);
- Establish your professionalism and responsiveness;
- Refer the patient back to their provider when there is a concern or recommend other professional resources (dietitian, mental health professional, certified diabetes educator, etc.).
Consider the following tips:
- When communicating with a health care provider, use concise documentation and focus on functional outcomes and disease-specific data that may be affected by the physical activity intervention. Use the Initial Fitness Assessment/Physical Activity Plan and Patient Fitness Progress Report samples. Send initial assessment notes and periodic updates (every 3-6 months) to the provider. If your client tells you about an upcoming visit with his/her physician, this is an ideal time to send a progress report or ask the client to carry one with them to the appointment.
- You may keep a detailed record of your client’s exercise regimen and fitness measurements, but a summary of the most relevant data will be most appreciated by the provider–and may be read! This requires thoughtful decision-making about what’s likely to be clinically meaningful to the provider. You may also wish to report data related to program compliance (attendance, exercise volume) and/or achievement of recommended physical activity levels.
- Always protect the privacy of any patient/client information. If the fitness facility where you work has a formal partnership with a health care system, it is your responsibility to be aware of the basic tenets of HIPAA legislation and follow them. Don’t discuss a patient’s medical history, personal health, or fitness information with other clients or staff, unless your client has given written permission for you to do so. To enable communication between you and the client’s health care provider, the client will likely need to sign a release of medical information form at the provider’s office.
- Health care providers have clinic schedules and obligations that are stressful and time-consuming. They typically won’t have time to speak with you during a busy clinic day. Rates of stress and burnout are at an all-time high. Physicians must rely heavily on a support team of medical and office staff to see patients and manage their practice. Anything you can do to make life easier or work through other designated members of the team will be appreciated. Ask when/how you can contact a provider if needed, i.e. phone, text or email, particularly if you have questions or concerns about their patient’s response to exercise.
- Technology solutions: As health care systems explore ways to track and monitor patient health data and treatment compliance, mobile applications and digital tracking devices are beginning to be utilized. If you can enter patient data directly into one of these platforms to automatically sync with the patient record, that is ideal.
Typical Sequence of Steps During a Patient's Office Visit
1. Patient moves from waiting room to exam room, where a medical assistant:
- Measures the patient's weight, blood pressure and other vital signs (hopefully including the PAVS);
- Asks the patient the reason for their office visit;
- Asks the patient what medications they are currently taking;
- Leaves the patient in the exam room, informing them that the health care provider will be in shortly.
2. Health Care Provider (MD, DO, NP, PA) enters the exam room and:
- Reviews the patient's chart, looking at the reason for the patient's office visit, their body weight, blood pressure, and medications being taken, as well as any other relevant historical data;
- Reviews/discusses the results of any tests made prior to the office visit;
- Discusses areas of concern expressed by the patient or identified in the health history;
- Makes appropriate recommendations to improve or manage the patient's health.
- It is during this last ("recommendation") phase of the office visit that a health care provider can and should recommend exercise as a treatment solution and identify any activity limitations.
- This is also the time when the health care provider could make a recommendation or referral for the patient to consult with a physical activity resource either within (physical therapy, cardiac rehabilitation) or outside the health system (fitness facility, exercise program, exercise professional).
3. MA or LPN returns to the exam room to follow-up with the patient and ensures that the patient understands the provider’s instructions and next steps regarding:
- follow-up testing or appointments
- educational materials recommended by the provider
- referrals or prescriptions
Having a successful referral relationship with a health care provider or medical practice will allow you to make a difference in the lives of those who can benefit most from increased levels of physical activity. You will expand the health care provider’s reach and effectiveness by providing services that they don’t have the time nor the ability to deliver. Health care providers want to see how their patients benefited from your intervention – show them results to confirm that you delivered.