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Therapists’ Interventions among Practice Settings
Published in Amy J. Litterini, Christopher M. Wilson, Physical Activity and Rehabilitation in Life-threatening Illness, 2021
Christopher M. Wilson, Amy J. Litterini
Details of the patient’s social network and support system will be essential information to gather. Does the patient have a family in the area? If they are in the area, do they have other obligations (e.g. work or childcare) that may compete with their ability to help the family member? In addition, the therapist must have a clear understanding of the individual’s primary disease process, extent of disease, current treatment regimens, and their effectiveness. Furthermore, a thorough review of co-morbid disease processes and surgery is needed to establish whether they may affect the individual’s physical activity performance. In cases of PC or other chronic disease processes, the care notes from the IDT are relevant and important. These would include the overall medical opinion from the attending physicians, an admission note (often known as a history and physical [H&P]), and consultants’ opinions of any symptoms or side effects of treatment. Useful consultation notes to review include those from oncologists, cardiologists, pulmonologists, physical medicine and rehabilitation, and orthopedics. For example, if the patient was having chest pain or experiencing new lower extremity pain after a fall, the therapist should thoroughly review the cardiologist’s or orthopedic surgeon’s notes, respectively, to determine whether physical activity may worsen an evolving or undiagnosed medical condition.
Cardiac Arrest
Published in Ian R. Gray, Medical Anecdotes and Humour: Myocardial Medley, 2018
It was less than a year since Patrick Martin had worked in hospital and not too many years since he was a medical student. He recalled teaching hospital consultants waving scraps of paper allegedly from GPs, asking him to ‘Please see and treat.’ He recalled even more clearly the condescension displayed by housemen (less sensitive than he) who had doubtless been shown the same letter in their formative years, to some GPs (who could not even be bothered to write an admission note at all) and rued the contempt with which doctors could dismiss events described by others – whether patients or other doctors – which they had not witnessed themselves. Patrick reflected that he did not save lives very often in general practice, and certainly not in such a dramatic and unequivocal manner, so on this rare occasion he controlled his outrage with some difficulty when informed officially that his patient had merely fainted. Even the patient seemed to know better than that.
Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum
Published in Medical Education Online, 2023
Justin J. Choi, Jeanie Gribben, Myriam Lin, Erika L. Abramson, Juliet Aizer
A series of three full-day clinical reasoning examinations (CREs) were held bimonthly over the semester (February, April, June 2020). For each CRE, students were given Part 1 of a written clinical case. Part 1 included a History & Physical Examination (H&P) note that provided case information from the chief concern through diagnostic testing results as one would read in a standard hospital admission note (omitting the assessment and plan sections). This ‘whole-case’ approach allowed for standardization of case information available to each student, avoiding reliance on students to elicit the history given their limited experience eliciting histories from patients. Cases were more complex than those used in other case-based learning small groups and integrated content from the organ systems the students had learned about to date (the first CRE involved the heart and the lungs; the second added gastrointestinal and renal processes, and the third added hematology/oncology and endocrine conditions). Cases were peer-reviewed by the organ system unit leaders.
Validation of ICD-10-CM surveillance codes for traumatic brain injury inpatient hospitalizations
Published in Brain Injury, 2020
James Warwick, Svetla Slavova, Joshua Bush, Julia Costich
Documentation of a TBI-related diagnosis was taken from clinical provider-authored notes within the electronic medical record. Clinical provider notes for the inpatient stay included the discharge summary, admission note, and any progress or consult notes authored and signed by the clinical provider. The reviewer used the clinical provider notes as the main source of information to gather evidence and respond to the following question: “TBI, concussion or similar diagnosis documented in the clinical provider’s note (No; Yes, known; Yes, suspected)”. Medical terms indicating documentation of a TBI diagnosis within the clinical provider notes (e.g., intracranial haemorrhage (subdural, epidural, subarachnoid, intracerebral, intraventricular), traumatic intracerebral haemorrhage, acute traumatic intracerebral haemorrhage, delayed traumatic intracerebral haemorrhage, traumatic brain injury, traumatic intracranial haemorrhage, concussion) were adapted from the previously mentioned multi-state study (14, 15). The reviewer consulted a trauma surgeon when the interpretation of medical record notes was ambiguous. If the study reviewer responded “Yes, known”, we considered this record a true positive record for TBI, justifying the assignment of a TBI surveillance code.
Improving Completeness of Surgical Inpatient Medical Records in Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
Published in Hospital Topics, 2023
Berhanetsehay Teklewold, Goytom Knfe, Firaol Dandena
A focused group discussion and key informant interviews were held with physicians and nursing staff in the department to identify gaps in findings of incompleteness. Several actions were taken to improve the completeness of inpatient medical records after a base line study finding. The interventions made wereAwareness and sensitization creation on the importance of completeness of medical recordsModification of the forms to have specified places for all necessary information.Preparation of a separate admission note where the identification of the patient and admitting physician and diagnosis are written.Continuous monitoring and evaluation system by the daily collection of the chart review by assigned junior residents.Continuous evaluation of medical record completeness of charts by the daily morning meeting leader.Presenting the findings of the chart review results in the regular monthly morbidity and mortality conferences for discussion.Established a recognition system for the wards with the best performance based on the physician and nursing documentation parameters.