On my current clinical placement I recently realised how necessary it is to communicate with other staff members. I always realised it was important to know what was happening in all aspects of care with the patient however if I couldn’t understand somebody’s writing in the integrated notes I wasn’t too fussed skipping over it. One of my patients is an elderly woman who has been in hospital for several months due to repeated NOF fractures and a total hip replacement. She has been mobilising with a WZF and we thought she would be fine to be discharged with this as she had reported having only one step on entry to her house.
As this patient does not always have the best memory I looked through her notes and realised there were several different entries from different people stating the number of steps this woman has to enter her house ranging from 0 to 4. Obviously if there is any more than 1 she would not be able to be discharged with a frame and must be able to use crutches if she is to return home. I discussed this with the OT who had not realised there were variations in the notes. Through further discussion with other staff members we were able to ascertain that this patient will require to be uisng elbow crutches to enter her house.
Although I always knew it was important to discuss things with other staff members this situation strongly reinforced it. Since this, I have always made certain I read the notes thoroughly and whenever I am not clear on anything I will always discuss it with other staff.
4 comments:
I think thats a really good point Trace. Its often very tempting to skip majority of the notes in a patient file in order to save time. It outlines the importance of a multidisciplinary team working together and communicating effectively.
I concur, in previous pracs i have found that there were quite large discrepancies between notes and the best ways to deal with this is to collaborate with other members of the team as well as the patient. But remember in some cases patients (especially in the elderly) may have memory issues, or be confused or disorientated due to the illness, and may be giving conflicting answers, this is where it is important to ask family members or visitors for their assistance. Again this requires co-ordination with the nurses as you can ask them to contact you when a family member arrives as you may not necessarily be around.
It is a good point. Since I still have difficulty dealing with English (writing, reading, speaking), it is always tempting for me to skip some of the medical notes especially with unreadable hand written.
One day when I was reading a medical note, I never thought about a patient in one of my group had Dx with CF. I discussed with my supervisor and she did not know of it either. This group was not for CF, so we were kind of worried why this patient was in the group.
Later on, I found out that medical notes (actually two pagies) were not the patient's. For some reason, another patient's notes got into this patient's medical chart.
After what happened, I was really careful reading and more paying attention of the chart and always discussed with my supervisor.
i totally agree, though its not awlways easy talking to nurses. Some of them like havong physio students on the ward as its an extra pair of hands, and some.. well some really don't like us.. It has made it challenging because evry nurse requires a different approach, some more helpful than others. i have found the allied health team great to get along with, but some others nurses, doctors, surgeons you really have to be ont the ball with how you approach them.
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