For every client I have seen this placement I have first read a discharged patient physio referral from the ward physio (including some from fellow students!). Certain instances have given me reasons to consider more carefully the notes I have read and consequently the notes I then write.
For instance - every client I have seen has been reported as being independent in bed mobility. Yet some of the clients cannot get their legs up onto the bed without assistance and many of the clients have demonstrated that once in bed they are unable to roll onto their side and are uncomfortable lying on their back but they just put up with it. There are obviously some valid reasons for this discrepancy between what is reported and what I am seeing at the client's home such as - hospital beds being height adjustable which makes it easier to get in/out of bed, and having side rails to help a client turn over while many clients do not have these options at home.
However this is just one example off the patients referrals, there are many more I could give.
This placement has made me re-evaluate how I read/interpret patient notes, and I now take a little more time with the client to help confirm and clarify information on the referral. In addition it has made me think more about the information I write in my patient notes. I find myself asking 'what information would I have liked to have known about this client, prior to seeing the client, that the previous physio would have already known but hasn't given me that would have helped me provide a better service to the client'.
Students are sometimes advised not to write so much in their notes (I was told on this placement- "if you write too much - no-one will bother reading it") but i think we need to be mindful not to go to the other extreme of writing too little.
1 comment:
I also find that sometimes the notes are inconsistent eg L and R and that makes it really confusing. There is a big difference between a patient presenting with L hemi and R hemi.
Also, in terms of patient mobility, although us as physios can do a 2 persons assist transfer, but we won't necessarily write that on the mobility charts- because we are trained better to transfer patients. So we must be clear in that sense to state clear in notes that nurses should be hoisting the patient instead of doing the 2 assist transfer physios has been doing - in case they hurt their backs !
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