Planning in the Consultation and Clinical Notes Using a Person-Centered Structure

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Werdie van Staden


Background: The concluding part of a clinical consultation and its recording in clinical notes typically comprises the ‘plan’ or ‘further management’, which guides further actions regarding tests and investigations, treatments, counselling, referrals and follow-up.
Objective: The objective of this article is to consider how this part of the consultation and clinical notes may be structured in an explicitly person-centered way, more so than merely in a patient-centered way.
Methods: The tenets of Person centered Medicine are applied to the standard objectives of the planning section of the clinical consultation. Using an informal case study, this application is contrasted with applying too narrow an understanding of Person centered Medicine as if the same as patient-centered medicine.
Results: The planning section is conventionally structured in biopsychosocial domains, but it is typically formulated as the clinician’s plan and is rather unilateral in presenting the clinician’s perspective. Although at times implicitly incorporating the patient’s contributions, the patient’s voice does not routinely feature explicitly in the plan or the patient is merely required to understand, commit and adhere to the plan. In contrast, the planning section may be structured explicitly in a person-centered way and reflect co-production and shared decision-making. This may be achieved by deliberately adding the headings ‘co-produced’ and ‘co-decided’ and by requiring that the entire plan be informed by not only medical/health expertise but crucially by that which matters to the patient in that individual’s context (including concerns, expectations, values, preferences, aspirations and strengths).
Conclusion: Clinicians and medical educators should optimize ‘the plan’ section of the consultation and the clinical notes by which to foster a routine that is more person-centered and that lives up to the requirements of shared decision-making and co-production.

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