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A complete record at the assessment stage in the care process will show: ° the details of any relevant history ° the details of assessments administered and examinations or investigations carried out effective 40 mg propranolol cardiovascular disease causes, along with the date these were performed ° the results of these tests buy cheap propranolol 80 mg on-line cardiovascular disease cold feet, investigations and procedures ° diagnosis (and prognosis where applicable) ° actions arising out of the assessment (for example referral elsewhere, advice, waiting list for treatment) ° identification of the type and extent of clinical intervention ° prioritisation information ° plans for future management that include a date for review ° the client’s views and concerns regarding the above information ° the name and position of the clinician who evaluated the client. Key documents to be kept on file at the assessment stage: q a case history form or admission sheet q forms or charts used in tests, investigations or procedures q consent forms signed by the client giving permission for investigations RECORD KEEPING 53 q a copy of any reports or letters circulated about the initial assessment q copies of referral letters to other agencies or health professionals q copies of any information provided by the client or family. Intervention A primary function of the personal health record is to describe the actions taken to meet the needs of the client. You need to show that your care for the client was planned, regularly monitored and the outcome evaluated. Your notes will also include evidence of the client’s involvement and agreement with your proposed plan of care (Moody 2001). Planning intervention The purpose of any intervention is to achieve a positive effect on the health status of the client. This might be in their physiological, psychological, be­ havioural, social or developmental function. The main aims of intervention are: ° to anticipate and reduce the risk of any deterioration in health status or function ° to ameliorate problems and restore premorbid or developmentally appropriate levels of functioning ° to maximise the client’s level of functioning within the limits imposed by their current health status ° to preserve the current level of health status or functioning ° to prevent or delay deterioration in the client’s health status or level of functioning ° to increase the client’s knowledge and skills in coping with the health problem ° to support the client and the client’s significant others in accepting and coping with the client’s health status or level of functioning ° to alleviate the psychological or physiological discomfort or distress of the client. Before commencing intervention you will have formed a plan of action based on your reason for care, which needs to be noted in the client’s per­ 54 WRITING SKILLS IN PRACTICE sonal health record. You may write it directly into the progress notes of the client’s personal health record, or you may be required to complete a careplan. Care pathways (or clinical pathways) are a recent initiative to develop a standardised multidisciplinary careplan that describes key interventions along a timeline. They include expected outcomes and outline the main stages in the clinical management of the client. Care Pathways are being developed for specific procedures and client groups. However, as a clinician you might also be involved in creating an indi­ vidualised plan for the client, either because there is no documented path­ way or the specific needs of the client require an individual management plan. Careplans describe: ° your intended actions for the client ° your objectives (what the actions will achieve) ° the timeframe. Careplans are evidence that the care for the client was planned and that there was a clear rationale to support the clinical decision making. They also provide a written record to which other health staff are able to refer thus ensuring continuity of care. Writing a careplan Part of writing a careplan is selecting the most appropriate objectives for your specific client. Remember to: à Set objectives with the client and not for the client The client who participates in setting his or her own goals is more likely to understand and be committed to the care process. In some cases the priorities might be obvious, for example acute clinical need must be addressed first. However, much of your decision making will RECORD KEEPING 55 involve establishing what the priorities are for the client. This will often involve negotiation and compromise by both you and the client. They have been developed by multidisciplinary experts using sound scientific evidence. These factors will mean that the type, amount and length of intervention will vary between clients. For example, the development of independent living skills may be difficult in a hospital setting where meals and so on are provided. Remember that goals set in conjunction with the client are more likely to be something that he or she feels is achievable. This will help avoid any duplication and ensure that goals complement rather than contradict each other. Again care pathways (or clinical pathways) provide a multidisciplinary perspective on the management of the client. For example, an objective about a client self-administering medication will be contraindicated in a setting where organisational or professional guidelines prohibit this.

You may write it directly into the progress notes of the client’s personal health record discount propranolol 80mg on line blood vessels neck, or you may be required to complete a careplan discount 40 mg propranolol fast delivery cardiovascular disease in china. Care pathways (or clinical pathways) are a recent initiative to develop a standardised multidisciplinary careplan that describes key interventions along a timeline. They include expected outcomes and outline the main stages in the clinical management of the client. Care Pathways are being developed for specific procedures and client groups. However, as a clinician you might also be involved in creating an indi­ vidualised plan for the client, either because there is no documented path­ way or the specific needs of the client require an individual management plan. Careplans describe: ° your intended actions for the client ° your objectives (what the actions will achieve) ° the timeframe. Careplans are evidence that the care for the client was planned and that there was a clear rationale to support the clinical decision making. They also provide a written record to which other health staff are able to refer thus ensuring continuity of care. Writing a careplan Part of writing a careplan is selecting the most appropriate objectives for your specific client. Remember to: à Set objectives with the client and not for the client The client who participates in setting his or her own goals is more likely to understand and be committed to the care process. In some cases the priorities might be obvious, for example acute clinical need must be addressed first. However, much of your decision making will RECORD KEEPING 55 involve establishing what the priorities are for the client. This will often involve negotiation and compromise by both you and the client. They have been developed by multidisciplinary experts using sound scientific evidence. These factors will mean that the type, amount and length of intervention will vary between clients. For example, the development of independent living skills may be difficult in a hospital setting where meals and so on are provided. Remember that goals set in conjunction with the client are more likely to be something that he or she feels is achievable. This will help avoid any duplication and ensure that goals complement rather than contradict each other. Again care pathways (or clinical pathways) provide a multidisciplinary perspective on the management of the client. For example, an objective about a client self-administering medication will be contraindicated in a setting where organisational or professional guidelines prohibit this. This is partly an unacceptable risk when compared with recognised best practice, and also what the individual client deems an unacceptable risk. Clients will vary in risk acceptance, and this will influence their decision making about treatment regimes. Therefore it must be made clear to the client about any likely risks or negative outcomes arising from intervention, for example the side effects of a specific drug regime. Careful explanation of these risks is required if clients are to make informed choices about their treatment. These choices will depend on the client understanding and accepting potential and actual risk. Such a discussion needs to be recorded in the notes in order to provide the clinician with protection from any future litigation. Recording clients’ decisions regarding consent to treatment It is essential that whenever possible, consent is obtained from the client before the start of treatment. Consent, whether it is given verbally, in writ­ ing or by implication, must be recorded in the notes. Your records also need to show not only that the client consented but also that he or she was capable of making this decision. The client must have sufficient informa­ tion to consider the benefits and the risks of the proposed treatment in or­ der to make a decision (Rodgers 2000). It is the clinician’s responsibility to make sure that the client under­ stands: ° the nature of any procedures ° the likely positive and negative outcomes ° the risks. Part of this explanation might include the option to ‘do nothing’ and the associated benefits and/or risks.

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Increasingly generic 80mg propranolol with mastercard heart disease over 65, it is the coroner’s assistant who decides whether or not you actually need to speak to the coroner and these assistants can occa- sionally be a little supercilious 40mg propranolol fast delivery coronary artery unroofing procedure. G name and address of the patient G date of birth and the time and date of death G date of and reason for admission to hospital G mode of admission, for example GP referral, via the A&E department or elective admission G in-patient diagnoses and treatment G background medical history G what you think the cause of death was that you are intending to write on the death certificate, that is Ia, Ib, Ic and II G name and telephone number of the next of kin There are certain times when it is mandatory to report the death of a patient to the coroner, for example death due to an accident or violence. These are changing with time and the patient affairs or bereavement affairs office in your hospital can provide you with an up-to-date list. Dress Code and Personal Hygiene Clothes All professionals should dress appropriately, particularly doctors. Men should wear clean, ironed shirts and trousers (not combats) and a tie. Men should shave daily 28 What They Didn’t Teach You at Medical School Surviving the Pre-registration House Officer Post 29 30 What They Didn’t Teach You at Medical School Give the ward and hospital This means you will gain financially from the death of the patient. The answer should be “No” The ordinary medical attendant is the GP As the hospital doctor, you should write “No” Your examination should be external only Has a post mortem been performed? Answer “Yes” or “No” This should read the same as the Death Certificate Figure 4. It is inadvisable to state that the patient died alone “No” “No” “No” “No” “No” e. BSc, MBBS It is mandatory to circle YES or NO on (a) and (b) to allow cremation. NB: radioactive implants, pacemakers and inflatable orthopaedic nails explode and are potentially harmful and must be removed prior to cremation by the undertakers or morticians Figure 4. It is not acceptable to turn up to ward rounds or meetings with relatives looking like you have not left the hospital for three days. If you are prone to body odour and your shirt smells,then bring a spare when on-call or wear theatre blues and change them in the morning. Women should wear trousers or skirt with an appropriate top (not exposing too much cleavage) as it draws the attention of not only your male colleagues but also the patients! I have seen two female PRHOs get nee- dle stick injuries in their feet that were preventable. The first was by dropping a needle and syringe and the second was by stubbing a toe on a needle at a medical emergency. Most juniors (myself included) often wear trainers with surgical scrubs when on surgical take (particularly nights) as they are more comfortable and easier to run in (to trauma calls/emergencies), but as you become more senior you spend less time on the ward at night and so have less need for them. However, when you are standing up for most of the day and night spending long hours in uncomfortable theatre clogs, most people find trainers a real pleasure! Just do not turn up to the post take ward round in them or you will probably feel your consultant’s shoe leather on a cer- tain posterior aspect of your anatomy. This is usually a very effective method of your boss conveying which type of shoes he or she prefers you to wear. The head of department is usually the most senior doctor or in a teaching hospital a professor. Each department is further divided into clinical and non-clinical staff who must all interact at a professional and personal level to ensure the smooth and efficient running of the department (Figure 5. Within each medical and surgical department there are several teams or ‘firms’, which are usually led by a single con- sultant with a specialist field. These firms are simply a group of doctors who provide care for their group of patients. Occasionally two consultants may join forces to pro- duce a single large firm, for example respiratory, urology or vascular surgery. Each firm has its own specialist registrar (SpR), senior house officer (SHO) and/or pre- registration house officer (PRHO). In the case of a double firm there may be an SpR for each consultant and the SHO and PRHO work for both. A firm usually runs from a group of specialist wards,but nursing staff work for the ward and not the firm. The purpose of having specialist wards is to concentrate expertise in one field to one place in the hospital and therefore increase the excellence of care, as patients have faster access to specialist doctors, nurses and professionals allied to medicine (now called allied health professionals: see the chapter on ther- apists and professionals allied to medicine) and it has been shown that there are fewer clinical errors in these settings. This means that you are respon- sible for the organisation and day-to-day running of things.

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Jaffe was a devoted and fiercely loyal friend to those of his colleagues with whom he collaborated and whom he respected buy propranolol 80 mg without a prescription blood vessels exploding. He was revered by his students and especially by the hun- dreds of house officers in the New York area who attended his conferences and learned pathology from the man who “wrote the book purchase 80mg propranolol overnight delivery cardiovascular system powerpoint. Jaffe had a life outside of the hospital, but it was Arthur Rocyn JONES indeed a rich one. The Arthur Rocyn Jones, consulting surgeon to the older, Arthur, was Professor of Mathematical Royal National Orthopedic Hospital, died peace- Physics at Harvard University in Cambridge, fully at his home on Stanmore Hill on February Massachusetts. The last 3 years, a period entertaining but liked to spend time with their of increasing frailty, had brought several alarms family and close relations even more. Jaffe about his health and once a spell of some weeks loved to garden and approached this activity with in hospital, but a strong Welsh constitution always the same passion as his scientific pursuits. He came to the rescue, keeping him on his feet with constructed a terrace on the grounds of one of a clear memory of the exciting events of his early their homes in Pelham and raised flowers, except career in orthopedics, almost to the very end. He for a brief period during World War II when he, was equally sustained by the deep but unobtrusive like many of his neighbors, converted it to a Christian belief that had governed the conduct of victory garden. He Over the years, Rocyn, as he was known affec- had an extensive record collection and often tionately, forged a strong personal link with the attended concerts. The Jaffes vacationed in early days of orthopedic surgery in Great Britain. Jaffe enjoyed In 1918, sponsored by Elmslie, the thinker, and outdoor activities with his wife and children. Bankart, the man of speedy action, he had been The worlds of pathology and radiology, and elected a founder member of the British Ortho- especially orthopedics, are deeply in the debt of pedic Association, of which in due course he this extraordinary man, who in his lifetime became the historian. To mark his 85th birthday, brought order to the chaos of bone pathology, the number of The Journal of Bone and Joint served as the final arbiter for countless puzzling Surgery for May 1968 was dedicated to him. The cases, and brought enlightenment to a vast warm appreciation it contained, from the flowing 163 Who’s Who in Orthopedics pen of Jackson Burrows, gave so many accurate Baschurch in earlier days, and to Oswestry in later and felicitous details of his life and influence. So, too, at Roehampton in the years of For many years, Rocyn was a close friend of the First World War, his enthusiastic spirit of hap- Muirhead Little, who gave him some priceless piness made wounded soldiers believe that life relics of his father W. All his apprenticeship was the safe keeping of the Institute of Orthopedics, served with his uncle Hugh Owen Thomas, the which he helped to establish in 1946. Liverpool was the first center of his activities; then it was London; then Great Britain; then the United States; and then the whole world. It is not a far cry to see that whether in surgery or in any other activity, great men do not remain parochial, or local, or national, but rather international and worldwide in their endeavors. The humble origin of Robert Jones in this small Welsh town led ulti- mately to a great British–American alliance in the world of surgery, and then to his establishment of the International Society of Orthopedics and Traumatology, of which he was the first president, this body of surgeons expressing almost inarticu- late admiration by creating for him the unprece- dented title of “Permanent President. Robert Jones qualified in medicine in 1878, and gained the Fellowship of the Royal College of Surgeons of Edinburgh in 1889. He was soon appointed general surgeon to the Liverpool Robert JONES Stanley Hospital and, while still a young man of 1857–1933 30 years, general surgeon to the Royal Southern Hospital of Liverpool. This broad surgical expe- The kindly word, the encouraging smile, the twin- rience stood him in good stead in later years, kling eye with creases all going up in the right when his abilities were applied to that part of direction, and the whole magnetic personality of general surgery concerned with disorders of the Robert Jones, seem as vivid today as they were limbs and spine—orthopedic surgery. He was of 30 years ago when he was at the peak of his course strongly influenced by his uncle Hugh endeavor in creating and establishing the princi- Owen Thomas, to whom he was apprenticed at 11 ples, science and art of orthopedic surgery. Nelson Street—the house that became a Mecca Perhaps his greatest contribution was to the art of for surgeons from all over the world. We have surgery because he taught us all to be so infec- said that Hugh Owen Thomas was descended tious in our happiness that disabled and distressed from a long line of Welsh bone-setters; but even patients also became happy. I never knew a more his father Evan Thomas, unqualified as he may joyful man with his quips, pranks, jokes and have been, treated thousands of patients not only beaming smile, so that when he went to from the industrial north of England but from 164 Who’s Who in Orthopedics every corner of the globe. Robert Jones could London, though always maintaining his free hardly have escaped this traditional influence, or Sunday clinics at Nelson Street. But before he did the powerful personality of his uncompromising so, his alliance with Agnes Hunt had been created uncle, who battled and fought continuously in and firmly established. She had first brought chil- favor of safe and conservative treatment as dren from her derelict country home at Baschurch opposed to unsafe, sometimes wild and often in Shropshire, where stables had been converted dangerous operations. So every Saturday she a wrench concealed beneath his coat-tails to would arrive in Liverpool with two or three correct a recently malunited Colles’ or Pott’s frac- perambulator-loads of crippled children for ture before the patient had time to breathe or Robert Jones to operate upon, and take back a wonder what it was all about; and here it was that similar number of loads to Baschurch. From this Robert Jones learned not to waste time, and to very simple, undignified, perhaps illicit, some- know the great possibilities of conservative treat- times naughty, but always happy and joyful activ- ment.

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