Week5 day2

Today was fairly hectic I had two new patients to see and two for discharge one on Wednesday and the other on Thursday. The first patient I was to do a dicharge COV's assessment, however the Gerontology assessment form was missing from the file, apparently quite a few documents have been misfiled as we have had a turnover of several ward clerks since I have been working there. This made some extra work for me as I had to re-assess the patents ROM and recall what the COVS entries were originally, this was one of the first patients Elle and I saw on prac, "originals lost" were then entered on the form. I filled in a problem list, treatment aims, patient/discharge goals and discharge summary as part of the gerentology assessment form for the two patients being discharged and a discharge summary form.

One of my strategies for improving my clinical reasoning with a more logical approach as mentioned in my blog last week is to write out new patients details from their file as if I was giving a handover, then prepare a potential problem list from the information gleaned from their notes and write a list of what I will assess and why based on what I have identified. This is similar to the A and P in a SOAPIER. Unfortunately one of my other issues is that I am slow with paperwork and all this writing made me even slower so that it was a rush to get everything completed and my notes written and signed by the end of the day and I felt bad that everybody had to wait around for me.

Despite this I think it is a worthwile exercise for me and has helped me to order my thoughts, particularly writing shortened SOAPIERS before entering a SOIER in the patient notes. However I still need to become more efficient at reading patient notes and faster with the paperwork.