Subjective Assessment in Clinical Preparation

• Main Areas of Subjective Assessment:

  • demographic details
  • presenting condition
  • history of presenting condition
  • past medical/surgical history
  • drug history
  • social history
• Subjective Assessment - Demographic Details:

  • name - correct patient and what they wish to be called
  • hospital number
  • date of birth
  • address
  • next of kin
  • consent
  • consent for sharing information with other health care professionals
• Subjective Assessment - Present Condition:

  • diagnosis
  • reason for referral
  • patients main problem - their view of the present condition
  • patients perception/understanding of condition
  • patients understanding of your role/role of team
• Subjective Assessment - History of Present Condition:

  • date of onset/when first noticed
  • how did it occur
  • behaviour of symptoms
  • progression
  • investigations so far/results if known
  • medical management
  • other management (e.g. ultrasound)
  • previous therapy and effect
  • other agencies involved
  • mood/yellow flags
  • red flags
• Subjective Assessment - Past Medical Surgical History:

  • comorbidites
  • pervious surgery
  • communication
  • technology dependence/special equipment
  • risk factors
  • allergies
  • red flags
  • MJ THREADS
  • Myocardial infarction
  • Jaundice
  • Tuberculosis
  • Hypertension
  • Rheumatoid Arthritis
  • Epilepsy
  • Asthma
  • Diabetes Mellitus
  • Stroke
• Subjective Assessment - Drug History:

  • is pain controlled
  • what they take
  • has this changed or increased recently
  • hows it administered
  • do they take their medication independently
  • has mode of administration changed?
  • NKDA (No Known Drug Allergies) - checking if pts have any drug allergies
• Subjective Assessment - Social History:

  • where do they live, are there any steps/stairs
  • do they live with people or do they live independently
  • how do they mobilise/walk
  • does they cook independently, are they involved in a service
  • do they go to the shop, do they online shop, are they struggling
  • do they take transportation or drive
  • what are their hobbies
  • do they drink alcohol or smoke and if so, how much - affects recovery time
  • do they have pets, can they look after them
  • do they still work
  • whats their overall mood
• Communication - Nonverbal:

  • first impressions are important
  • demeanour, attitude and dress all influence your pts impression of you
  • you dont necessarily need to be formal in your address, but do be polite
  • showing concern for your patients situation is important
  • what nonverbal cues are you picking up from the pts
• Communication - Verbal:

  • make sure you are speaking to the correct patient
  • introduce yourself as a student physiotherapist
  • state your purpose
  • consent
  • questioning style
• Vary Situations:

  • empathy
  • dealing with emotions
  • patients who are too ill to talk
  • those who are confused
  • communication difficulties
  • transcultural issues
  • relatives/carers
• Health Record:

  • any record which:
  • consists of information relating to the physical or mental health or condition of an individual and
  • has been made by on behalf of a health professional in connection with the care of that individual
  • may be paper or electronic or both
• Regulatory Framework:

  • HCPC (2012) Standards of Conduct, Performance and Ethics (for students)
  • standard 2 - you must respect the confidentiality of service users
  • standard 10 - you should keep accurate record on service users
  • HCPC (2013) Standards of Proficiency (Physiotherapists)
  • be able to maintain records appropriately
  • CSP (2012) Quality Assurance Standards
  • 10 - Be able to maintain records appropriately
• Legal Framework pt1:

  • Data Protection Act (1998)
  • concerned with accuracy, storage and destruction of data
  • Access to Health Records Act (1990)
  • right of access to a deceased pts health records by specified persons
  • Access to Medical Reports Act (1988)
  • governs release of commissioned reports of living pts for insurance or employment purposes
  • Freedom of Information Act (2000)
  • gives people the right to access official information from public, medical and health organisations
• Legal Framework pt2:

  • Computer Misuse Act (1990)
  • an offence to gain unauthorised access to computer materials (e.g. another persons username or smartcard without their permission)
  • Human Rights Act (1998)
  • health records are closed as private and covered by the Act (right to respect for private and family life
• Where is information recorded?

  • physiotherapy notes
  • medical records
  • MDT records
  • electronic records
• What should be recorded?

  • pre-assessment information (subjective assessment)
  • presenting condition
  • history of presenting condition
  • past medical/surgical history
  • drug history
  • social history
  • assessment information (objective assessment)
  • observation
  • use of specific assessment tools/techniques
  • palpation/handling
  • outcome measures
  • if any of the required information is missing or unavailable, reasons for this must be documented
• What should be recorded?

  • problem list
  • impairments - relates to body function & structure
  • activity restrictions - relates to participation
  • participation limitations - relates to activities
  • analysis
  • clinical reasoning
  • subjective markers
  • objective markers
  • physiotherapy diagnosis
  • treatment plan
  • interventions
  • time scale for implementation
  • who will deliver intervention
  • risk assessment
• What should be recorded?

  • interventions
  • physical
  • advice and information
  • communication with patient and multidisciplinary team
  • review and modification of
  • assessment
  • treatment plan
  • evaluation of treatment plan
  • discharge plan and report
• Writing Clinical Records

  • pts records should be:
  • started at time of initial contact
  • completed immediately after contact with the pts or by the end of the working day
  • dated and timed on left hand side
  • legible, factual, consistent and accurate using bullet points
  • detail care and treatment given
  • identify problems and actions taken to address them
  • signed after each entry/attendance (student notes are countersigned by the clinical educator or other qualified physio)
  • name is printed after each entry/attendance
• Writing Clinical Records

  • patient records
  • do not use correction fluid
  • any errors are crossed with a single line and initialled
  • pages are numbered
  • patients name, date of birth, hospital number or NHS number are given on each page
  • abbreviations - used only in the context of any locally agreed abbreviations policy
• Physiotherapy Student Clinical Records

  • HCPC (2016) Guidance on Conduct & Ethics for Students
  • "you should make sure that any information you put in someones record is accurate and clear"
  • "you should protect information in records from being lost. damaged, accessed by someone without permission or tampered with
• Where should information be stored:

  • security
  • ward/clinic environment
  • electronic records - password protected computer (secure log in)
• Where should information be stored:

  • long term storage
  • dependent on patient
  • children/young patients either 25th or 26th birthday (if 17 years at conclusion of treatment) or for 8 years after death
  • mental health patients (children) - as above, adults - 20 years after last contact or 8 years after death
  • physiotherapy records - as above
  • physiotherapy diaries - for 2 years after conclusion of year to which the diary relates
  • paper discharge books - 8 years after final entry
  • outpatient lists - 2 years after the year to which they relate
• • Who owns the clinical record?
  • NHS
  • Private Practice
  • Private Health Service
  • Industry
  • Who can access the clinical record?
  • Patient
  • Patient Representative
  • Clinicians