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Physiotherapy Case Study. A patients prognosis may be greatly enhanced if serious or life threatening conditions may be diagnosed early (Greenhalgh & Selfe 2006). This is particularly true of a Deep Vein Thrombosis (DVT), which involves a clot or thro

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Introduction

SCHOOL OF HEALTH AND REHABILITATION NAME OF COURSE: physiotherapy MODULE TITLE: PPD/PBL 3 ASSIGNMENT TITLE: PPD/PBL 3: Reflections WORD COUNT: 1487 (495, 496, 496) Please note that the stated word count for each piece of course work is an ABSOLUTE MAXIMUM N.B. tables, diagrams, figures, text boxes all count as 100 words (Unless stated different by module leader) HAND IN DATE: 21/06/10 COMPLETE COPY yes (INC DECLARATION OF OWN WORK, APPENDICES ETC) I have read the relevant information in the handbook relating to coursework requirements and have complied with these. yes 1 Essay 1: Patient A patient's prognosis may be greatly enhanced if serious or life threatening conditions may be diagnosed early (Greenhalgh & Selfe 2006). This is particularly true of a Deep Vein Thrombosis (DVT), which involves a clot or thrombus forming in a deep vein. This condition if left untreated carries a high risk of a pulmonary embolism (Kumar & Clark 2009) and highlights why awareness, attention and suspicion are just as important in clinical reasoning as structured protocol (greenhalgh & Selfe 2006) A patient presented, as a fracture clinic referral, with a diagnosis of an avulsion fracture to the tibial spine. On observation, there was clear, but minimal swelling around the patella. Range of movement and isometric quadriceps exercise were prescribed and a physiotherapy appointment for two weeks later was arranged. On the second presentation the swelling was still uni-lateral but much more widespread, covering most of the upper thigh and some of the lower limb, and the tenderness had moved from the patella to the medial aspect of the upper thigh. ...read more.

Middle

According to the CSP Core standards (2005) each individual entry must be dated, signed after each entry and every sheet clearly labelled with the patients name and either their date of birth, hospital number or national health service number. Throughout the placement I consistently omitted one of the above mentioned details. Whilst writing patient notes I concentrated and focussed on writing clear, concise, logically sequenced and accurate notes as echoed in the CSP Codes of Conduct (2005), but often forgot to include the small details, which could generate 8 significant adverse consequences with regards to their legality, and thus open myself up to charges of negligence. (CSP 2005). Approximately three quarters through the placement when these omissions became consistent my clinical educator took me aside for a conference. She explained to me that the content of my notes read well, were logically sequenced and contained all the pertinent information but were none the less fundamentally flawed due to my continued omission of a signature, a date or a name on the continuation form. Not only did this invalidate a statutory legal requirement (CSP 2005) she explained that if continuation forms were mislaid and the name had not been recorded at the top then it made deciphering ownership extremely difficult. She elaborated, suggesting when I became a junior I would not benefit from the continual mentor appraisal bestowed as a student and that un-completed notes would then slip through the system and become in-validated as a legal document thus exposing myself to legal recourse in some circumstances. ...read more.

Conclusion

The importance of non-verbal communication when interacting with patients. 18 Reflective account: essay 3: documentation Describe a recent event in your professional life. During my recent student placement I repeatedly forgot to sign certain medical note entries and sometimes failed to complete continuation sheets by omitting the patients name or other identifying features. What did you do ? Failed to complete patient medical records with the appropriate validation. Discussed the matter with my clinical educator with a view to improving. And why ? The placement required five or six individual sheets per assessment and time was limited throughout the day due to other demands. The placement was new to me and I tended to focus on other aspects of note writing not realising the significant consequences of in-valid medical records. What went well ? 19 My clinical educator informed me that my notes read well, they were logically sequenced and contained the relevant information. What could have been better if anything? I could have been more aware of the legal status of medical notes. I could have focused and concentrated more when note writing. What if anything would you now do differently, faced with a similar situation ? For my next placement, being now fully aware of the implications, I will endeavour to concentrate much harder when undertaking the writing of patient medical records and to manage my time more effectively, with particular regard to the validation process Describe what you have learnt from this experience ? (Learning outcomes) The importance of medical records to inform clinical decision making, consistent approaches to treatment and to aid communication. A deeper understanding of the official nature and legalityof medical records 20 That writing medical notes demands concentration and focus at all times ...read more.

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