Going forward, I feel it is important to keep an open mind when assessing patients, many signs and symptoms do not sit squarely within classic patterns (Maitland 2006) or protocols, echoing the CSP (2005) guidelines of not assuming with regard to physiotherapy delivery. Furthermore, clinical
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reasoning should never be complacent, the physiotherapy path is one of life long learning not of dogma. (Higgs & Jones 2000)
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Essay 2: communication
With regards to clinical reasoning and assessment, much of the relevant information is attained from the patient, and effective communication is essential (Higgs & Jones 2000). In addition treatments and education should be patient centred, specific, realistic and achievable (CSP 2005). Thus, to achieve positive outcomes, the clinician must cultivate an environment which decreases intimidation and relaxes the patient enough to express themselves clearly and honestly (Hengeveld & Banks 2005). Effective communication is a two way process, however the clinician is accountable for its efficiency and every effort should be made to understand the patient and to use non verbal communication to express empathy. (Hengeveld & Banks 2005)
Many patients worried about a condition and its health related and societal consequences often find themselves in a state of anxiety. For many the alien hospital environment compounds this emotion. A method I utilised to express my compassion and to put a patient at ease was via an aspect of non linguistic communication, termed interactional synchrony (Koss & Rosenthal 1997) or postural echo (Morris 2002). When friends of similar values and attitudes interact they consistently adopt similar or mirrored postures, movements and rhythms (Hove & Risen 2009). These
actions are performed autonomically, and send out a message of similarity and like-mindedness (Bernieri & Rosanthal 1991).
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I researched further and discovered how this simple technique could be applied to healthcare. In the clinician-patient relationship the therapist is in the dominant position and is thus ideally placed to help the patient to feel at ease (Morris 2002). Because acting in unison subconsciously conveys equality and affinity, a therapist may consciously help a patient to relax by copying their body displays (Koss & Rosenthal 1997). Hengeveld & Banks (2005) echo this, suggesting that awareness and use of the body with mirroring can greatly enhance communication. For example one patient entered the cubicle and sat quietly, leaning back with crossed arms . I sat opposite in a similar posture subtlely copying his bodily movements. This helped the patient to visibly relax and he became quite animated and his closed posture opened up, and answers became more detailed. By echoing my patients’ posture and movements I was able to neutralise my dominant role within the relationship to one of equal status friendship and thus converse accordingly (Morris 2002). This enabled me to extract a deeper understanding of my patients perceptions and of any yellow flags or social barriers to recovery (Hengeveld & Banks 2005). Additionally ,this allowed me to cultivate the development of a positive therapeutic relationship, which is often cited as critical to a patients recovery. (Hengeveld & Banks 2005)
Going forward I feel it helpful to bear in mind the dominant role a physiotherapist has when treating patients and, additionally is much more comfortable in a clinical environment than a patient, thus to treat a patient
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effectively techniques that help a patient to relax and decrease anxiety play a significant role in the extraction of relevant information. (Hengeveld & Banks 2005)
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Essay 3: Documentation
If high quality, legal and evidence based health care is to be provided for the patient then medical records are an integral resource. They enable a consistent approach to treatment, inform clinical decision making and aid clear communications. (CSP 2005) Furthermore, the chartered society of physiotherapy renders them a professional requirement in all physiotherapy practice, (CSP 2005) and increasingly in this litigious age they are classed as an official document with regard to any legal proceedings (CSP 2005). As well as being a critical aspect of a clinician’s duty of care towards the patient (CSP 2005)
With regard to medical records at the City general hospital Orthopaedic outpatients, entries are myriad and include documented notes, body charts, exercise sheets and continuation forms. 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
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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. Medical records are protected under the Data Protection Act (1998), The Human Rights Act (1998) and the Public Records Act (1958). Additionally the clinician is bound by a personal common law duty of confidence. (CSP)
On reflection my clinical educator’s remarks were constructive and extremely pertinant, it would appear that I channel all my focus towards the records content and not enough towards the organisation and the validation process.
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Going forward, I feel I now understand that medical records are not just about content and substance but that structure and the validation process are just as important in terms of completeness and legal admissibility. Indeed, to comply with the CSP Codes of Conduct (2005) it is a mandatory requirement.
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References
Bernieri FJ, Rosanthal R 1991 Interpersonal co-ordination, behaviour matching and interactional synchrony. In Feldman RS, Rime B (eds) Fundamentals of non-verbal behaviour, Cambridge University Press, Cambridge
CSP (2005) Core standards of physiotherapy practice. The Chartered Society of Physiotherapy, London
Greenhalgh S, Selfe J 2006 Red flags. Elsevier Churchill Livingstone, Edinburgh
Higgs J, Jones M 2000 Clinical reasoning in the health professions. Butterworth Heinemann, Oxford
Hengeveld E, Banks K (Eds) 2005 Maitland’s peripheral manipulation 4th edition. Elsevier, Edinburgh
Hove MJ, Risen JL 2009 Its all in the timing: interpersonal synchrony increases affiliation. Social Cognition 27 (6): 949-961
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Koss T, Rosenthal R 1997 Interactional synchrony, positivity and patient satisfaction in the physician-patient relationship. Medical Care 35 (11): 1158-1163
Kumar P, Clark M 2009 Clinical medicine 7th edition. Saunders Elsevier, Edinburgh
Morris D 2002 Peoplewatching the guide to body language. Random House, London
Petty NJ 2006 Neuromusculoskeletal examination and assessment 3rd edition. Elsevier Churchill Livingstone , Edinburgh
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Reflective account: essay 1: Patient
Describe a recent event in your professional life.
During my student placement a patient presented for an initial assessment with a diagnosis and symptoms for an avulsion fracture of the tibia. At the patients follow up session the presenting symptoms had changed and the patient was subsequently diagnosed with a femoral deep vein thrombosis.
What did you do ?
Upon follow up observation it was apparent to me that the patients symptoms had changed, the pain had moved from the tibia to the groin. The swelling had changed from a little around the patella to widespread swelling of the upper and lower thigh. The area at the medial aspect of the the upper thigh was also red and hot. Realising that continuing treatment was beyond my scope and training I went to find my clinical educator
and why ?
We are bound by rules and regulations, that help safe-guard a patients well being and also by a duty of care to any patient. These clearly state that treatment or assessments must not go beyond the scope, training or skills of
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the clinician. It is important in physiotherapy to understand your limitations so that no harm comes to the patient because of clinician negligence.
What went well ?
I observed changes to the signs and symptoms of a presenting patient that did not dove-tail with the general patterns of the original presentation.
I understood that these symptoms could have significant consequences for the patient.
I realised my limitations and sought consultation from a mentor.
What could have been better if anything?
I could have had more knowledge of the signs and symptoms of deep Vein Thrombosis.
What if anything would you now do differently, faced with a similar situation ?
Apply the same diligence equipped with more knowledge and experience.
Recognise this condition when faced with it again
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Describe what you have learnt from this experience ? (Learning outcomes)
Symptoms don’t always follow text book patterns patterns.
Keep an open mind and never pre judge expectations.
Understand why it is important to realise ones own limitations.
The importance of intuitive awareness that follows training and experience.
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Reflective account: essay 2: communication
Describe a recent event in your professional life.
I successfully recognised a patient’s trepidation and anxiety and was able to relax the patient by utilising my own non verbal communication skills
What did you do ?
Employed a body language technique that neutralised the dominant position a therapist holds over a patient to convey feelings of empathy.
Helped the patient to relax by employing a non verbal communication technique called interactional synchrony
And why ?
The patient was feeling particularly apprehensive and anxious so in order that the assessment was constructive, I tried to relax the patient. This enabled me to extract a deeper understanding of the patients perceptions of their injury and of any yellow flags or social barriers or to recovery, additionally this allowed me to cultivate the development of a positive therapeutic relationship, which is often cited as critical to a patients recovery.
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What went well ?
The technique was employed with subtlety so as not to come across as contrived, which may have heightened the patients anxiety.
The patient visibly relaxed, and I was able to extract poignant, personal information that may have hindered recovery.
What could have been better if anything
Better understanding of cultural differences within ethnic minorities
What if anything would you now do differently, faced with a similar situation ?
This was an example of a simple technique, not often discussed, heralding significant results. I hope to refine my non verbal communication skills in trying to relax patients in intimidating environments.
become more aware of cultural differences
Describe what you have learnt from this experience ? (Learning outcomes)
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That a relatively simple technique can herald significant results.
Patients are more forthcoming and honest if relaxed and rapport can be developed.
The dominant role a physiotherapist holds in the clinician, patient relationship and how this may be utilised positively.
The importance of non-verbal communication when interacting with patients.
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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 ?
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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
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That writing medical notes demands concentration and focus at all times