Advice:
When doing a medical recording in the outpatient clinic, indicate the purpose of consultation.
In the medical records of the patients, the physician should indicate this purpose categorization as much as possible to facilitate patient and medical records management, particularly in terms of communication. Writing down the purpose of the medical consultation will determine what will or should be written down in the medical records.
When a patient goes to a medical clinic of a physician for medical consultation, defined as a meeting between the physician and a patient for health related issues, there are generally four categories of purposes:
First-time consultation
Follow-up after initial consultation
Check-up after initial consultation
Consultation for new health concern after initial consultation
In the medical records of the patients, the physician should indicate this purpose categorization as much as possible to facilitate patient and medical records management, particularly in terms of communication. Writing down the purpose of the medical consultation will determine what will or should be written down in the medical records.
First-time consultation
If a patient goes into the medical clinic for the first time for whatever reasons, such as for checkup (to screen for a health problem) or for resolution of a health concern, the purpose categorization is first-time consultation.
After the initial consultation, the purpose categorization may be follow-up after initial consultation, check-up after initial consultation or consultation for a new health concern after initial consultation.
Follow-up after initial consultation
If a patient goes back to the medical clinic after the initial consultation, with the physician needing to provide continuing or further treatment or attention to something as an offshoot of the initial consultation, the purpose categorization is follow-up after initial consultation.
Examples:
A patient coming back for result of a biopsy done 3 days ago is under a “follow-up” categorization.
A patient coming back after a diagnostic procedure done outside the medical clinic is under a “follow-up” categorization.
A patient coming back after a watch and wait (observe and monitor) management set-up is under a “follow-up” categorization.
A patient undergoing a minor procedure and asked to come back for after procedure treatment such as removal of stitches is under a “follow-up” categorization.
Note: A patient not previously seen in the medical clinic but seen and managed in the hospital or elsewhere and is asked to go to the medical clinic for follow-up is under “follow-up” categorization.
Check-up after initial consultation
If a patient goes back to the medical clinic after the initial consultation, if there is no more active medical or surgical condition or urgent medical procedural or test outcome for intensive continuing or further treatment or attention to something, just screening, then the purpose categorization is check-up after initial consultation.
Examples to show the difference between "follow-up" and "check-up":
One week post-op for removal of stitches and tube drain in patients undergoing a total mastectomy with checking of wound is under a “follow-up” categorization. One month after removal of the stitches and tube drain with checking of the wound and operative site is under a “check-up” categorization. Patients coming back for result of a biopsy done 3 days ago is under a “follow-up” categorization. Cancer patients coming back for recurrence surveillance purpose three months after previous consultation is under a “check-up” categorization.
At times, there may be a gray zone or transition zone between “follow-up” and “check-up” services. In which case, a tag of “follow-up / check-up” is placed.
Examples:
In observing a medical condition for diagnostic purpose after a month or so (specific example: follow-up / check-up after one month or 2 months such as in patients with a high probability of fibrocystic breasts).
In watchful waiting for a medical condition that has a high probability of spontaneous resolution (specific example: follow-up / check-up after two to four weeks of observation such as in patients with a diagnosis of reactive hyperplasia of the lymph nodes).
Consultation for new health concern after initial consultation
If patients goes back to the medical clinic after the initial consultation complaining of a new medical problem unrelated to the previous ones, then the categorization is neither follow-up or check-up but a first consult for the new problem or a consultation for new health concern after initial consultation.
Summary:
First-time consultation
Reasons for consultation: patient needing screening for a health problem (layman term: check-up) and management of a health problem or concern.
Follow-up after initial consultation
Reason for consultation: physician needing to provide continuing or further treatment or attention to something as an offshoot of the initial consultation.
Check-up after initial consultation
Reason for consultation: physician and patient needing to do surveillance for possible recurrence of a health problem that has been resolved previously.
Consultation for new health concern after initial consultation
Reason for consultation: patient needing screening for or management of a new health problem or concern.
ROJ@18dec18;18dec21